to the Advanced Foot and Ankle Challenging Conditions Expert Teaching Course. Tonight kicks off the second day of strategies to tackle your toughest cases. Thank you to course chair, Dr. Peter Mangone, along with co-chairs, Dr. Errol Bailey and Kelly Hines for putting together such a fantastic course. And thank you to all the faculty for their participation. Before we get started, I wanna share a few housekeeping items. All faculty will share their disclosures during their individual presentations. And you could also find them within the virtual platform under speakers and disclosures. This course offers a total of 14.5 AMA PRA category one credits. Use the tile on the platform landing page to claim CME at the end of this course. The broadcasts are being recorded and will be available under on-demand recordings on the virtual platform within 24 hours of the broadcast. All on-demand recordings will be available on this platform until October 31st, 2022. And then we'll be available on the PRC to view whenever you like. To send questions to the faculty, please click on the Q&A tab in your navigation bar. You are also welcome to use the chat to communicate with other attendees or faculty, but please be aware that everyone can read what you write in that area. If you experience technical difficulties, please try closing your browser and logging back in the same way you did the first time. If you would like to ask a question using your microphone, please click on the raise hand icon and a moderator will call on you and staff will unmute your microphone. Lastly, we want to thank our sponsors of this course, Stryker, Treece Medical Concepts and Artalon. You can learn more about these companies by visiting the exhibit hall icon on the platform landing page. With that, I will turn the program over to Dr. Peter Mangone to get started. Thank you. I appreciate it. I just wanted to say thanks again to the AOFAS staff for all the work you guys are doing to help us with this course. I want to thank the faculty members for the time that they've donated to lend us their expertise. Thank the attendees of the conference. Thank you for being on and we appreciate you. Without you, we don't really have a reason to be here. So hopefully this will give you some good information that you can carry back to your practice and your day-to-day activities. Also, once again, reiterate our sponsors, Stryker, Treece Medical and Artalon, that if you get a chance to see those virtual breakout rooms for them, great. If not, if you see them at the next meeting, please thank them for the sponsorships. They help us and our corporate partners are very important. To reiterate, if you have questions, try to use the Q&A or chat function, ideally the Q&A function. And just to be aware, we may answer some of those while the course is going on. Some of them we may group together and answer together afterward, or we may address them individually during the case discussion period. So we appreciate your time and efforts. We've got two great sessions. The first session is on ankle arthritis and comprehensive solutions, moderated by Dr. Younger. And the second symposium today is on cavovirus and metatarsus adductus deformity with our moderator, Kelly Hines. So I'll turn it over to Dr. Younger. Thank you very much. Hello, everybody. Evening and welcome to the ankle arthritis session. So I'd like to go in right away and introduce our first speaker, who is Jesse Doty, who is from the University of Tennessee College of Medicine in Chattanooga. And he is an associate professor for the University of Tennessee orthopedic surgery department. So Jesse is going to talk to us about osteotomies, joint salvage with osteotomy and ligament reconstruction. Jesse. Okay, thank you. Thanks to Dr. Mangone, Bailey, and Hans for the opportunity to show a few cases and the AOFAS for helping put together this event. So we'll get started. We have a few minutes to go through some of the salvage options. And I really, when I was given the title of this talk, I think probably the biggest indicator is salvage to avoid ankle fusion and what's really become more of a mainstay of treatment, ankle replacement. And so these are my disclosures. And so some of these are gonna be more obvious than others. It's a patient who had surgical fixation of a fracture six months prior, and then came to my office with clear malunion of the fibula with shortening syndesmosis malreduction, and then a non-union malunion of the medial malleolus. And so I think a CT scan can be beneficial in these cases, and particularly also to compare to the other side. In this scenario, one of the things that makes this a little bit easier to build back is just maintaining your talus in an optimal position centered in the mortis. This is a trick taught to me by my trauma colleagues using a large pin across the posture aspect and post your malleolus into the calcaneus to help you restore some degree of stability while you begin to rebuild. Restore your length of your fibula, restore the integrity of the syndesmosis. And then, of course, the bone quality, as you would imagine in the medial malleolus, was soft. And so more fixation than would typically be anticipated for an acute fracture. But in the end, again, once the alignment's maintained, I think this is a good option rather than, number one, leaving the patient in a malreduced position where, based on Dr. Sanders, probably the most quoted JOT article on syndesmotic malreductions, and we know the outcomes of those. And so here we are at four years, not a perfectly, not a beautiful joint or 100% maintained joint space, but I would argue that perhaps we bought this patient some time. Some of these can be more subtle. This is a 21-year-old who's had an ankle ligament repair in the past. Actually, I did her repair years prior, and I think that was the right answer at the time. I'm less inclined to do an osteotomy for the first pass. Maybe I should have. But in any event, a young patient, again, full-length tibia views to evaluate the actual mechanical axis of that bone. This is one where we did a simple opening wedge, and you can see the screws broke, but fortunately she had some degree of healing. The other thing, a couple of nuances that can keep you out of trouble with these. This is a young patient, so I chose to go ahead and cut the fibula. Sometimes I won't. There's some data that shows that the magnitude of tibiotalar tilt correction and the magnitude of intraarticular deformity is more aggressively corrected when you do a fibula osteotomy. This is a young patient, so we want to do everything we can to maintain the integrity of the ankle and not affect the syndesmosis complex in a negative way. So the other thing, again, looking at the studies that are out there, that one thing that's beneficial in my research for putting this talk together, for every millimeter of opening wedge, according to Dr. McGarvey and colleagues, you can expect about two degrees of angular correction of the tibial plafond. And so that's just another beneficial equation you can use for your pre-op planning. So here's a 40-year-old with medial ankle pain, instability, lateral instability, and failed brostrom. This patient actually had an augmented ligament repair years ago. Again, another one of my failures. I saw her back in 2016. So she did have some good years. I did her revision surgery this year, actually, but she had another injury where she fell. She also starting to have medial joint line pain. And if you look at her updated MRI, you start to see she already had some wear on her medial talar dome. And so again, doing an opening wedge osteotomy, I think the spade tool is super useful because you can dial it in in real time intra-op. The other thing in this case, not surprisingly, 15 to 20% of patients with lateral ankle instability also have subtle syndesmosis injuries that can be seen on her MRI. And then the shift test with arthroscopy, there was a degree of mobility there that I wanted to address. To be critical of this case, you can see I've fractured the lateral cortex. And in review, there is a safe zone where you're less likely to experience a fracture. And so that zone is actually just above the syndesmotic articular cartilage. So if you look at the plane of my osteotomy on the left, I was probably a little bit proximal in the direction I aimed, and I should have exited the tibia a little bit more distal, and perhaps I wouldn't have sustained the fracture. You can see there on the screen. The other benefit of going lower versus more proximal with your osteotomy, and here you can see these authors described it as a proximal and a distal. The more distal you are, the more powerful the correction in this most recent article that was just published in FAI. And so yet another reason probably to angulate your saw blade a little bit distal. So in all these cases, I think it's important just to remember the basic tenets of what we've been taught with limb deformity correction. Full-length weight-bearing mechanical axis views, evaluating the real way to do this is the center of the femoral head to the center of the ankle. And then if you have mechanical axis deviation, medially it's going to be more of a varus-type mechanical axis, and laterally it's going to be valgus, and that's for the entire limb. Once you've established that the limb has a deviation, then you have to look at each bone individually to see what degree of contribution each bone has to the overall alignment. And for us, fortunately, as foot and ankle surgeons, generally by the time the patient gets to us, it's well-established that it's the tibia, but there are times when it's important to x-ray the entire limb. The other beauty of the tibia is there are different methods for measuring how you're going to obtain your alignment and how you're going to do that within an acceptable means. The anatomic axis is really the mid-difficile line for the tibia, and then the mechanical axis is drawn off of the joint lines. And for the tibia bone, those are within a few millimeters of each other. And so really any clinical difference is irrelevant and you can use them interchangeably. The other thing, when you're looking at the mechanical axis, there are two really important angles, the medial proximal tibial angle and the lateral distal tibial angle. If you look at the normal values for those, it's easy to just throw it all out the window and remember 90 degrees because that's well within the normal values for all these angles. So remember 90 degrees proximally and distally, and then 10 degrees posterior slope, 10 degrees anterior slope, and those are just some generalizations that are probably going to keep you out of trouble. So again, to determine really where the deformity is, the two most common methods, the mid-diaphyseal method based off the center of the diaphysis, and then the joint line method where you draw normal, you draw your joint lines on x-ray and you see where those lines cross. And those lines are going to usually cross at the apex of the deformity. Once you've done that, you can draw your correction line, which is the center of that obtuse angle. And that's going to kind of help you know exactly where you're going to perform your correction. So if these lines cross far outside of the bone, then usually there's a secondary deformity or there's a translational deformity. So it's much easier when the lines, regardless of the method you use, when they cross within the bone. And so take this male union, for example, so middle-aged male, and you can see, again, using the mid-diaphyseal line proximally because I can't even see the proximal joint line, and then using the joint line method, again, drawing my joint line and then drawing this at 90 degrees off. And that gives you an idea of where your correction line is going to be. So again, I want to keep my correction as close to this red line as possible, because if I do it more proximal or more distal, I'm going to have some degree of translation. And so I did a dome osteotomy in this patient, and you may say, well, hey, you know, you did your dome more proximal than your correction line, but you have to remember with a dome osteotomy, the center of rotation's actually the center of that dome. And so this one ended up working quite nicely, again, fixing the syndesmosis to make sure that I didn't malreduce that. I did a fibula, long oblique fibula osteotomy, and usually I'll let that kind of fly into position, fix the tibia, and then see where that fibula ends up. And sometimes I'll put a single screw in the fibula, but again, making sure we don't malreduce the syndesmosis in this patient that hopefully has many more years to go on their native ankle. So here's another one, a little bit more severe deformity. This gentleman, of course, he has knee osteoarthritis, ankle osteoarthritis, and just to show you that there are multiple ways to skin a cat. And so you look, if you draw the joint line proximally and distally, then you'd suggest that the apex of your deformity would be more proximal. And we know it's not there just from looking at the X-ray, but you can still do your correction there. If you just did a proximal osteotomy shown here, again, they're gonna have some bossing immediately, but you've restored your overall mechanical access. The other way to do it, the anatomic or mid-diaphysial line method. Again, because these lines don't really cross in the bone at the deformity, you know when you do your correction, you're gonna have to perform translation as well. And so that's just something to think about. And then lastly, just doing a knee, sending this to your knee colleague for a knee replacement may be easier than all those. So this is a lady who had a malunion, distal tibia malunion, came to me. I always recommend utilization of interlocking bolts in your tibial nails, and not surprisingly, this happened. And so one thing that benefit as much as I hate doing frames, it can be difficult to realign these osteotomies acutely. It can be a bit intimidating. And the benefit of a frame is you can continue to run these total residual programs, and you can really dial in your correction in real time. And if you're not perfect, you can dial it in. And that's what Rosbrook showed. They had 52 patients in that series. Those patients had their frames on for four months on average. One of the important things of the frame, you can see I incorporated the foot. If you incorporate the foot for these distal deformities, then you're gonna get more stability as you do your correction. And then once you've obtained your correction and you're in the consolidation phase for those last couple months, you can take the foot plate off, allow the patient to walk, so you don't have to keep the foot incorporated the entire time. This one's pretty close, still a little bit of translational deformity, but patients will generally in the tibia accept up to about 50%. My preferred way to do it is like what we did on this gentleman. He had a tibial malunion, medial ankle pain of stress in his deltoid, medial pain in his knee from stress, as well as lateral joint line overload. And so it's easy to use an intramedullary nail because, and the benefits of that are you can use the nail as a realignment tool, load sharing rather than load bearing. And then you get the, it's just less metal loads. You get that confinement of your implant within the tibial canal. And I think tibia fractures all heal better with nailing historically. So here's a little bit different case. This is a 17-year-old male, subtalar pain, bilateral. He had a pretty generally neutral foot when I evaluated, but I was pretty convinced his pain was subtalar. So I did injections, diagnostic injections bilaterally. Indeed, his pain got better. He hurt in his deltoid, he hurt in his sinus tarsae, but again, he doesn't really have a flat foot when you look at his x-rays. Look at his mechanical axis and he's got overall valgus deviation of his mechanical axis. And so at the femurs, again, it's a little bit much, not way off. If you look at his tibias, certainly a degree of valgus through the tibia. And it's really through the entire bone. Again, looking at the different methods to measure mid-diaphyseal and joint line method, you can see not all the deformity is in the tibia because these cross outside of the bone, but he's definitely got a bow to his tibia. So we did these one at a time. You've probably seen this. This can definitely help for a dome osteotomy. The beauty of the dome osteotomy, you can get some degree of translation. It's a little bit powerful to help correct the overall valgus, a little bit more proximal. And then you just swivel, place a locking guide on a plate and just swivel that plate and drill your holes to make your osteotomy. And then just use an osteotome to connect the drill holes. Again, fixing the syndesmosis for stability. The old Bovey technique taught to us by our mentors where you center the Bovey line at the knee and at the ankle, and then you can measure your joint lines off that Bovey line and see if you've done anything to improve the patient. I generally use two plates for these. I've just found it's easier to use two Recon plates. And his pain went away on both sides. Here's a 48-year-old male, lateral joint line pain, malunion, again, not quite there for an ankle replacement. Can you buy this guy some more time? This one's pretty easy, medial closing wedge osteotomy. Cut the fibulus, you get some flexibility there. I think the benefit of a closing wedge osteotomy in a 48-year-old, you're gonna have good bone compression for healing. I've gone away from using that plate. I don't think that plate's very strong, but for a closing wedge, it's probably enough. Here's a 62-year-old who she had had six or seven surgeries by the time she came to me. I got her to quit smoking. Her infection worked up. We took her metal out. Everything was negative. Cleaned her up, did a little vacation with some antibiotic cement. And in this scenario, I think, you know, she had a nail right through the talus, the subtalar and the ankle joint. And she's, I think, 62 at the time. And so I do still think there's a role for knowing, even with combining with your osteotomy, knowing when to fuse. And she did quite well. And that's really what they showed in this study. I thought this was kind of cool because they compared supramalleolar osteotomy to arthrodesis. And you don't see studies where they're really two totally different modalities of treatment, but the ankle arthrodesis group fared better on multiple fronts, which I think is good. Doesn't mean we shouldn't do osteotomies, but we should know when perhaps a fusion or replacements may be a better option. Here's a 26-year-old, certainly too young for that. And again, a malunion with actually a pretty clean joint. After he jumped out of his girlfriend's window and her dad came in the room, he came back and disappeared a few times and finally made his way to surgery. This is an old study, over 20 years old, D'Orio first described me, called this fibula protibia technique. And I hadn't seen this article when I did it. And I put this talk together and I thought, wow, that was so cool that they published this years ago. But the fibula's already fused through the syndesmosis. See, this kid's young. I'm not so concerned about his ability to heal. And so I just autographed this and played it with a locking plate laterally. There he was at six weeks, there he was at six months, and then he disappeared back to whatever he does. Never saw him again. Here's a 53-year-old, medial ankle pain. You can start to see some narrowing there. MRI, I think it's always important to help you determine that degree of articular change. And again, scope is gonna be useful with all these cases. Most people would suggest scope the joint first, prior to the osteotomy. This one's kind of interesting. It's easy to be fooled. And if you look, you say, well, this patient has a flat foot. This patient had actually already had two posterior tibial tendon debridements, which had both failed. And it's because her posterior tib tendon was pristine. Her problem was the joint line medially. And she's got a varus talus, right? So for talus and varus, her foot's in compensatory valgus just to sit on the floor. And so if you do an opening wedge of the tibia, correct her talus position, you can see her hind foot's certainly not in valgus now without any procedure on the hind foot. And again, the hind foot and the midfoot realign just based on position of the talus. And so it wasn't really a foot problem. It was more of a positioning of the talus and the mortis and her medial joint line improved. Another one, again, narrowing of the medial. You see this from time to time where the medial gutter is just obliterated and the rest of the joint looks good. This is a super active military reserve lady in her fifties, still runs, very active. She's also got some degenerative changes in her midfoot. Again, if you look at her X-ray, her mortis on the left, you would think maybe she's going to have some valgus of her hind foot when you correct her tibia. But if you look at her correction, her hind foot's actually in a good position even after the tibial osteotomy. Her forefoot still in a little bit of varus once you correct that, the forefoot varus, which you can appreciate on her lateral. You see how elevated the first metatarsal is. That was exacerbated by the tibial osteotomy. And so we restore plantar flexion in the medial column, give her an overall plantar grade foot. And, you know, a little bit nervous in doing that in an active patient. But this study showed that their sports specific scores actually improved after osteotomies in these adult patients. And so it should give you a little more confidence. 62-year-old, again, medial ankle pain, anterior bony impingement. Another one maybe where is this patient a little bit on the younger side for replacement? Can we get another five or 10 years? So doing an arthroscopy to clean that out. You can see looking at the MRI, the narrowing of that medial gutter. Again, I would argue maybe this is a patient, even though much fewer and far between, maybe this is another one where an osteotomy is a good idea. I've used the locking guys from time to time just to help hold that open while you place your medial buttress plate. And I've had good success with autographed and mixed with DBM, particularly in patients with good, otherwise healthy patients, good biology and non-smokers. So I'll leave you with this last slide. I mean, how effective are these osteotomies truly? This is out of Henterman's group. If again, no surprise, but 44 patients. And I think if you look less than 10 degrees of talus tilt, 85% five-year survival of the joint. If they had greater than 10 degrees of tilt, 65% joint survival. And then again, the milder cases, tachycura II and IIIa, more success. And so these authors in the end said, look, osteotomy is a valuable treatment for early to mid-stage post-traumatic arthritis, which I'm inclined to agree with. And I went back and looked through these cases and looked at the longevity and some of the success we've had in these middle-aged patients. Thank you. Thank you, Jesse, for those really stimulating cases. And we'll, if you have any questions, put them in the chat and we'll address them later. I was going to get Errol Bailey now to speak on total ankle arthroplasty, principles of surgical correction. You've met Errol already. Errol is from Atlanta, Georgia. He's a Harvard graduate and was previously at Emory University School of Medicine. So Errol. Good early evening to everyone. Thanks for attending this meeting. I've been given the task of talking about principles of surgical correction and total ankle replacement. And what I want to do is teach you about patient selection, how to approach the ankle and how to basically stay out of trouble. These are my disclosures. I want to do this in a different way. I want to do this by doing a little bit of storytelling. I love to tell stories. So I hope you can follow me, but there'll be plenty of information in here as I do this. Let's say you're in clinic and you know how we're at our stations and you walk by and you see this X-ray in passing and you see this on the left and you go, hmm, that's interesting. Has this patient seen Jesse Doty? What's going on here? It looks like there's some osteotomy or something here, but there's certainly some various something's going on. Hmm. So immediately your mind starts to wonder, like who is this patient? I wonder what's the story. Can I do a total? This patient's going to need a fusion. What are going to be my concerns? So you walk in the room and the first thing the patient tells you is they're here for a second opinion. They've already died themselves with Dr. Google on the internet. So you're a little annoyed with them, but you stay in there and you hang in there with them and you get back at them by taking a very good history, like the doctor on the left, and you tell them, tell me everything you told my MA or my nurse five minutes ago, because you know you haven't read your intake sheet and you really have looked at the X-ray, but you plan to get most of the history while you're in there. So you take a good history. Patient's a little annoyed with you at this point because you're making them repeat everything over again, but you really need this information. So then you do a good exam and you have to touch the patient because in foot and ankle, as you know, X-rays lie. They can have significant arthritis and their problem could be posterior tibial tendinitis or peroneal tendinitis or something else totally unrelated to their bad X-ray. So you take the history and the patient tells you this. They're 50. So they're kind of young. You've seen they've got ankle arthritis already and that's what you found on exam. They're active. They play tennis. Diabetic. Had a bimalfracture that Jesse fixed 20 years ago. And there was a little bit of bone that poked out of the skin, but he did all right. Walks on the outside of his foot. Sometimes, doc, my foot gets a little numb, but it's not all the time. I do smoke a little, but I've stopped recently. I'm a little fat too, but my BMI is only 35. Oh yeah. I got a little osteoporosis too, doc. That's what they tell me. And by the way, your neighbor Marge sent me and you did her total ankle and I want one too. So immediately you look at all of these particular problems that this patient presents with and you turn into this guy. You're like, you've got to be kidding me. I'm just not going to entertain this. But then you calm down and then you start to feel sorry for yourself because you're wondering if there's some line out front that says, anyone with five to 10 comorbidities come see Dr. Errol Bailey because he's going to fix you up. And you really don't want to have anything to do with that. But you calm yourself down. And you say, well, you do have an extensive history here. So you tell them, the key thing, if we're going to even try to do this is patient selection. I kind of have to know you're the right one. So you go back out and you look back at these x rays and there's another one on the left that Jesse's done, and then there's what this one on the right. And you're going, well, maybe, I don't know, but she's got a lot of things going on here. So then your staff starts to look at you real funny, because you're really looking at this x ray and you're really thinking about doing something on this patient, and they're acting like it's the weekend update on Saturday Night Live. And they're telling you, wait a minute, come on Doc, patient's too young, they're active, they play tennis, the patient's diabetic for God's sake. All right. They say they don't smoke, but you know she's really smoking. What was that thing about the bone poking out of the skin. All right, there's got to be a bunch of incisions here. What's this numbness in the foot thing. Doc, you can't be serious, right. So, your response is this guy. Ah, don't worry. I got this, because I have plenty of data to support whatever decision I make. So then you go back in the room when you give them this State of the Union address on total ankle replacement. You tell them that 12,500 totals were done last year, not as many as you see with our counterpart with the hip and knee and shoulder, but they're increasing. And over the past 20 years technology has gotten really good complications are really down and five and 10 years of bios are up. And things are looking very promising for total ankles now, much better than they used to be. So you say, you know what, we're going to make this work. And then the patient starts coming at you with all these different questions which are appropriate. Half of them good, half of them bad like, you know, I have a trip planned three weeks after my potential surgery date, can I go swimming in Florida, with a three week old wound, things like that that they asked you, but pretty much their questions are pretty good. So the first thing they want to know is how long is this thing on a last. In this world of very difficult surgeries, is this thing going to work and how long is it going to stay. I am a infinity and inbound guy so the data I will show will mostly be for these, but they are also good and true for other types of total ankle replacements and I have to say that. There was a recent study of 503 infinity total ankles, done, and the National Joint Registry in England, multi center study 503 infinity total ankles, each surgeon had to do at least 10 a year, what they find complication rates, low and about 8%, but 97% of them survived with two years. The latest data out of the UK says that five years you got about a 97% survival as well. If you talk to Hodges and others who've been doing this fourth generation knee for nine years or so, they're saying that if you can get to five years, you're probably going to get to 10, but that data is not completely out yet. So they're working. Now, what about other joints does this work like other joints now, when you can actually tell your patients now that we've caught up total ankle replacement is pretty much as good. If not better than total knee. And it's as good as total hip and total shoulder. So that's not a concern anymore. What about age. This particular patient was 50, but we see them at 75 as well. How does that factor into this, does it really matter. One of the most recent and really good studies is good Tom, where he looked at 112 patients group them 55 years or less. 55 to 70 and 70 years and older. And the general conclusion from this study, and others is that age really doesn't matter. It's all about the quality of the patient. Now of course when you get rheumatoids in their height, high 30s or early 40s. That's another consideration, but by and large for degenerative arthritis. It simply does not matter. I play tennis. This lady says she's a tennis player. Can I play. So the answer to that is maybe, maybe you can play some doubles tennis. But how about some pickleball, that's something that everybody's doing these days. And the study that supports that is this one, 152 ankles. And what Valdebarano showed that patients with total ankles actually perform better with activity after total ankles than they did before. Now it wasn't terribly significant. There was 36% who were active before and 56% who were more active after, but there was a significance. Now these were hiking and biking and swimming, but still nonetheless they were more active. I have a number of people who play pickleball and doubles tennis, that has not been a problem. What about if you're this guy who's paralyzed from the waist out and morbidly obese and a BMI in the high 30s, or perhaps 40. Will this work. The impact on obesity on TAR was looked at, and there's been several articles, I just selected one for you, which shows that BMIs greater than 30 typically don't matter. In this particular study, there were 10 patients with a BMI of 40. And total ankle outcomes improved in both below 30 and above 30 BMIs. Now you can find other articles that say and beg to differ, but by and large the trend is obesity doesn't matter. Now you have to use some common sense. BMIs in the high 40s and early 50s probably aren't ideal, and those patients need to lose weight. What about if this lady on the left who has incredibly soft bone, sitting in the osteoporosis clinic, who passed gas and blew her tailbone off. Okay, that patient you're probably not going to want to do. But the average patient in her 70s who is losing bone at a normal rate of bone loss really isn't an issue. This study by Cody and others looked at preoperative CTs and bone density and found that if you use measured Hounsfield units, that Hounsfield units less than 200 had greater intraoperative fractures. And what they found was in osteoporotic patients, and you have two if you've done totals, it's really easy to fracture that medial malleolus, and you want to do prophylactic medial malleolus fixation, and sometimes you're going to have to add cement. So you don't have to avoid these patients, but you have to do them with extreme caution. What about deformity? Well, one of the most recent articles is by Lee, which showed that outcomes can do very well up to 20 and even greater than 20 degrees of deformity. If you're looking at a 91% overall success rate, varus is more difficult, and you can't leave them in varus. People will tolerate a little bit of valgus, but varus is wrong in fusions, and varus is wrong in total ankle replacements. What about diabetes? I've got a little sugar doc. Well, initially, I used to think that this was a major concern, and I still do to a certain point. But this study by Gross looked at the impact on diabetes and TARs and found no significant functional outcomes or differences. Interesting. However, again, you have to exercise caution. Check an hemoglobin A1c. If it's below 7 or 7.5, you're probably okay to operate, but if it's above that number, you don't really want to do this, you want to get this down. We always get this one, that patient was a little numb sometimes. What does that mean? What's a little neuropathy? Can we get away with that? Well, we all should have one of these in our office somewhere. I have several. I lose them all the time, and then I find them, but a Simms-Weinstein monofilament test should be done on everyone who has issues with numbness. Bottom line, if you do it and the protective sensation is okay, get an EMG. If it's normal, you're probably okay to operate. If they have no protective sensation on the Simms-Weinstein, you need to run or you need to send that to somebody else. Maybe we send that to Canada, to Alistair or someone else like that. Neuropathy, major, major, major caution. What if Snoop Dogg comes in and he's a smoker? Well, he's going to tell you he's not smoking anymore, but he ain't smoking any less either. That's what most of our patients do when they tell us they're not smoking. We know smoking kills and smoking and total ankle replacement patients, in my experience and in many studies, is bad news. This particular study showed increase in infections, increase in reoperations, increase in the number of revisions, and the general idea here is if they smoke, stay away, although you can find some studies that will tell you that's not the case. What about a little bone infection? That patient had a little bone that poked out of his skin. Well, ain't nobody got time for that, right? We hate staph infections. However, you can't be fearful of those. There's a way to work that out. In this particular study, this was looked at. What are you going to do? Jesse talked about this earlier about working up the patient. You do a bone biopsy if you're worried about infection. You get a WBC, a set rate, and a CRP. If it's all negative, you're probably going to be okay. This particular study, there was almost a nine-year interval from the issue of infection to doing the total ankle replacement, and no deep infections occurred. You can't be fearful of that. We've done patient selection. Now, let's get down to the bone. How do we get there? How do we stay out of trouble? How do we not shoot ourselves in the foot? We've all had this look of this old lady. We've done this beautiful total ankle, and then we look down and we see this, and we wonder, how in the heck did I get here? Well, the reason we get there is because our burden is greater than any other joint surgeon in any other part of the body. We don't have significant soft tissue to cover the ankle, and there's a foot underneath it. If you look at multiple studies, you'll see that our soft tissue infection rate is five to 10 times greater than our hand surgeons, total hip surgeons, and total knee surgeons because we simply don't have the soft tissue envelope. Our most common incision, the anterior incision. The evolving incision is the Tim Daniels extensile anteromedial incision. Lately, I've been experimenting with anterolateral incisions myself to try to avoid seeing that anterior tibialis tendon. We all know this approach. Some of us open the anterior tibialis sheet. I tend not to, but sometimes it opens on its own. The interval between the EHL and the anterior tib, and we get down to bone. How does that work? Well, this is a great study by Burlett and others, 304 patients with anterior approaches and TARs and ankle fusions. Look at this number. There's almost a 20% delayed healing, greater than 30 days in these patients. Now, they eventually get these to heal, but if you compare fusions to ankle replaces with anterior approaches, there's no significant difference. There are other studies out here that say the same thing. Here's Raken's study, 106 totals, 25% minor wounds, 8.5 major wounds that had to go back to the operating room. And if you're rheumatoid, beware. In his study, they had a 14 times greater risk. So when you're doing a patient with RA, be careful. Nunley confirmed the same thing. But what I want you to see here is the fourth line. They found that the major wounds that needed flaps or split thickness grafts, their surgeries were 26 minutes longer than the average time that it takes. So when you've got to take out hardware or you've got to do calc slides or tatum-lubricant fusions, you're adding time to your operation. Beware. Very briefly, I've used this before. This is a great approach, particularly if you've got a medial malleolar wound and you want to attach this to that wound instead of having train tracks from an anterior incision. This was Daniel's work. It's based on angiosomes, which are three-dimensional blocks of tissue supplied by arteries. There's six angiosomes in the ankle from three arteries. The picture that you see here, you're worried about the foot on the left. And you can see that an incision that I showed you goes along the anterior tibial angiosome and technically is more protective to the vascularity. There's an incision like that on the left, and here's a healed one on the right. A study in foot and ankle orthopedics with 73 patients. They had no skin flap necrosis. One patient with venous insufficiency and a superficial wound. So this works if you work it. What I've been experimenting with lately is I've had one or two wounds where I come back and I'm looking at my anterior tibialis tendon, and I decided to take a look at what this paper offered, going slightly more lateral and going in between the interval between the EDC and the EHL. And you can see where you go down through this retinaculum here. You can see where you're actually in good part of the retinaculum, so it's easy to get this closed and there's no exposed tendon anywhere after you close it. The cross section I want you to look at is the one on the right, where you see that you go down between the EDC and the EHL, and then you go medially and sweep the bundle laterally. When you close it, it looks like this on the right, but notice this picture. There's no anterior tibialis tendon in the wound. You can't see it. You never see it, and it's a beautiful thing. How does this work? This is a small study with 23 patients. They had no deep infections. They had no wound issues, but did get some blistering. The fibular approach, I don't do this, but it's out there. Studies comparing those wounds show that those issues with the wounds are similar to those that we see anteriorly, but of course there are issues with complications from fibular osteotomy, and the lateral approach tends to take longer. Once the wound goes black, you're in trouble. It's not going back. You probably need to find a plastic surgeon. It's time to pass the buck. What else can you do to stay out of this kind of trouble other than the incisions that you use? Negative pressure works. If you've got someone with two or three more comorbidities, there are studies out here that show that negative pressure, wound vac, preventer, et cetera, those do work. I don't have a single patient where I've used a vac on post-operatively that ever got a wound problem. I just, for some reason, don't do it because when they don't work at night and they stop working, the patients call you all night long, and it's a pain in the knee or what. However, they really, really, really work. How about diabetics? Topical vancomycin. Yes, yes, yes. It's cheap. It reduces deep infection. It reduces superficial infection, and it's only about five bucks per 100 milligrams. Why not sprinkle it in there? What about amniotic tissue? I say yes. I use this on everyone. This study by Davis, Hodges Davis, and there's others by Steve Newfield that show that this reduces dehiscence and reduces the use of antibiotics. Again, I say yes. Oh, my God. You get this patient. They've got multiple incisions, cardiovascular disease, they smoke, inflammatory disease, diabetes, obesity. What am I going to do? Well, for me, and I'll be interested in what the panel does, I always use amniotic tissue when I close everyone. Then, if they have no morbidities or very simple patients, I'll just do that and perhaps sprinkle some vancomycin into the wound. If they have two or three issues, they're diabetic, they've had a previous surgery, or there's something that's going on, I'm looking for an appropriate approach. I may add negative pressure. I definitely sprinkle vanco. I do the entire triple threat here to try to keep myself out of trouble. Now, as I wind this talk, we're down to the bone. I like to use PSI. It helps me. There are multiple studies that show that PSI gives you terrific neutral alignment when you use it. There are also studies that say that you can get very good results with standard instrumentation. It's not necessary, but it's very helpful because it does the following. It lets you see where your prosthesis is going to sit, whether you are doing an in-bone or some other type of prosthesis. It helps you identify where your hardware is and where your prosthesis is going to sit there, what screws, hardware, and plates are going to have to come out. Also, there are other views that will show you what the heel, varus, and valgus is after you've done the prosthesis. You may want to call the engineers back and have them tweak it a little bit to give you a little more heel, varus, and valgus. That's all there for you. Lastly, other surgical considerations. Medium allelis fractures. Nice study by McGarvey. You can get these up to 20%. Usually, it's from levering on the medium allelis when you're trying to pull out that piece of bone. Prophylactic screws are helpful. Lundin's work showed that you need to leave at least 10.2 millimeters to reduce the incidence of medium allelis fracture. His paper says 11 millimeters of medium allelis should keep you out of trouble. Pete's going to talk about complications, but nerve injuries occur 15 to 21% of the time. Of those nerve injuries, 40% are tibial nerve. You can blame it on the block if you want to, but oftentimes, you've done a little something to that tibial nerve back there, so you have to be really, really careful. Ligament balancing. If you have to do deltoid, you can do it from the wound. If you have to do something like a brostrum, you can make a small lateral incision and correct it appropriately. Remember, the foot sits under the ankle. Calcosteotomies are common. TN fusions, midfoot fusions, to help save your total. Lastly, valgus is forgiving. Varus is not. If you've got a lot of hardware, you're probably better to staging it, and make sure you make perpendicular cuts and not cuts that slope posteriorly, because that's going to give you problems when you try to put your prosthesis in. In closing, I like to always tell people I teach, it's important to stay in the right lane. You know, the right lane must turn right. You have to select the right patient. That's why I've gone all over this with you. Then you have to do the right thing. Sometimes it's not a total ankle. Sometimes it is, and if it is, sometimes it's an end bone. Sometimes it's something with an osteotomy, too, but you have to do the right thing. You have to do it the right way. Patient-specific instrumentation is very helpful here. If you do all these, that helps you get the right result. Thank you for listening. Thanks, Harold. Next, we have Konstantin Demarathokopoulos, who's going to talk to us about how to handle varus and valgus deformity. He works at a hospital for special surgeries. Konstantin? Well, thank you, everyone. Thanks to everyone for the invitation to speak. I'm going to talk about how to handle pre-op varus and valgus deformity. These are my disclosures. We've heard a lot about arthritis already, and we've heard some about deformity, and we know that deformity is common in patients with end-stage ankle arthritis. This study said about a third of patients have deformity, but I would argue that maybe these days, as we're expanding indications of patients that are getting ankle replacements, maybe even more patients have deformity, and we're tackling them with an ankle replacement. Deformity was historically thought of as a contraindication for ankle replacement. In 2006, many argued that it was more than 10 degrees was a contraindication. Well, then it was 15 degrees, and then it was 20 degrees, so it's been a bit of a moving target. Some older literature as well shows that incongruent joints are at a higher risk of edge loading. This was a study on a mobile bearing ankle replacement, and that patients who have a preoperative deformity are at a higher risk for need for revision. We know deformity is a problem, but this study in 2013 really showed that if you correct deformity at the time of the replacement, then your outcomes will be just as good as if those patients did not have deformity to begin with, but the key is to correct the deformity. This study was in 2013, and the results have been replicated by other studies more recently. In this study, they looked at patients with deformity up to 20 degrees, both varus and valgus deformity, and they found that with patients up to 20 degrees of deformity, they had similar results to those patients with a neutral ankle. Well, if it's good enough for patients up to 20 degrees, can ankle replacements be effective for patients past 20 degrees? This study looked at patients that had more than 20 degrees of deformity and also found acceptable results as long as the deformity is corrected. That's an important caveat. What about a meta-analysis? What if we group all the studies together? What does deformity tell us about survivorship? It tells us that varus can be corrected and can have similar survivorship as neutral ankles. But maybe valgus alignment may be a little bit more negative towards implant survivorship. And I would argue with Harold that I always, I worry about the valgus ankles, the preoperative valgus ankles a little bit more than the varus ankles. I think those can be a little bit tougher. And in this study here that looked at 15 degrees of valgus deformity, they found that for patients who had valgus deformity that was mild to moderate, less than 15 degrees compared to valgus deformity that was more than 15 degrees. Yes, you can get similar results, but the valgus patients that are severe need more additional procedures. And you've heard a little bit about this, that not only do we need to correct the deformity, but we need to balance the ligaments, balance the soft tissues and balance the foot. And in the patients with greater deformity, they may simply need more surgery to accomplish that. So is it safer to just fuse those patients? If patients have greater deformity, should we just not worry about replacement and fuse them? Well, this study looked at patients without deformity and with deformity, and they compared replacement and fusion. And what they found really rang true and makes sense. Patients with less deformity do better whether they have a replacement or fusion than patients with deformity. So having less deformity is a good thing. But if you do have deformity in the ankle, and if it is a severe deformity, whether you replace or fuse the ankle, the results are the same. Again, assuming you correct the deformity. So what about deformity? You've heard a little bit about it already. It can be above the ankle. It can be in the leg. It can be supramolecular. It can be intraarticular. So you can have congruent intraarticular deformity or incongruent deformity. And the deformity can also be in the foot. It can be in the hind foot and the mid foot as well. But what comes with deformity? Well, we can have ligamentous instability. It can be in the ankle. It can be in the foot. We have challenges with bone quality. Sometimes we have soft bone. We don't really know what to call it. We send them for a bone density workup, and it comes back normal, but we swear the bone was soft during surgery. Or we can have lack of bone. We can have cysts. And also prior surgery is always a challenge with these patients. So I'll show you some cases. Here's deformity above the ankle. Here's a patient with valgus ankle arthritis. You can see cystic change at the lateral distal tibial plafont. And when I had him walking in the room and sort of moving around, he moved awfully funny. So I asked him a little bit more about his history, and he said, well, I had a knee fusion many years ago. And you see there on the left, he has a knee fusion, but the knee fusion is in valgus, and he has valgus ankle arthritis. And so we have to correct the deformity before or during the ankle replacement. In this case, it was before. So he had an osteotomy of this distal femur, and then subsequently to that, an ankle replacement to correct the valgus deformity in the ankle. So you correct the deformity above, then you correct the deformity below. Now here's another patient who had varus ankle arthritis and underwent a supramolecular osteotomy. And you can see here that the tailored tilt correction is excellent, but we've induced a supramolecular deformity. And as arthritis progresses over time and the cartilage wears now, not only do we have the problem of end-stage arthritis, but we have associated deformity above. And so in this case, I treated this as a single-stage procedure to perform an osteotomy and correct the alignment and perform the ankle replacement underneath. And you can see here a lot of fixation because I realized it's a little difficult to impact the tibia when the bone is moving. So I had to put some extra screws and an extra plate to get things to be still, but you can do this as a single stage. And I published this study. These were patients from Duke University, Dr. Di Iorio, Nunley, and Easley of patients that had concomitant supramolecular osteotomy. And this can be done safely at the same time and certainly can also be staged. There's nothing wrong with staging this type of procedure. Okay, so what about varus ankle? So when I think of varus ankles, there's many possibilities, soft tissue and bony. Don't be afraid to release the deltoid. And often these patients will require a lateral ligament repair or reconstruction. Often varus ankles have a very tight Achilles. Maybe you can get away with a gastroc recession, but don't be afraid to lengthen the Achilles if necessary to realign the hind foot with a calcaneal osteotomy, balance the first ray with a first metatarsal dorsiflexion osteotomy. Certainly there's a role for dynamic balancing of the first ray, such as a longus to brevis transfer. In some cases, you can centralize the tibialis anterior or certainly can release or transfer the posterior tibial tendon. Can also transfer FHL to peroneus brevis. And for rigid deformities, for rigid deformities, we do have to consider hind foot arthrodesis. We want to avoid it, but a rigid capoveris foot is not amenable to soft tissue realignment, unfortunately. So here's a varus ankle. You can see prior surgery in the fibula, intraarticular deformity, prior surgery in the calcaneus. So here I'm performing a deltoid release, both a superficial and deep deltoid, and I'm going to correct the ankle. And I'm not going to make any cuts before I can correct the tibiotalar alignment. And once I do that, I can perform a cut on the tibia. I can perform a cut on the talus, and I'm going to reinforce the ligaments on the lateral side and tighten those as I've loosened the deltoid. And here you can see the implant in place. And I'm going to also address the first ray. Always think about the first ray and the hind foot alignment in these cases. So I did a dorsiflexion first metatarsal osteotomy. And here you can see the patient has good range of motion following this procedure. Now here's a larger varus deformity and a larger patient. So a larger intraarticular varus deformity, larger patient, hind foot varus alignment. So you can see here there's more components to this deformity, more severe deformity. So I'm going to use a different type of implant, a stemmed implant. I'm going to do the same thing with a deltoid release, a lateral ligament repair. I'm going to do a lateralizing calcaneal osteotomy. So this was a Malerba type osteotomy. Now I'm doing some MIS osteotomies, but still have open osteotomies available if I need them. And I'm also going to balance the first ray. So never forget to balance the first ray in these cases. So I did a dorsiflexion osteotomy of the first metatarsal. And here you see the preoperative hind foot alignment. And here's the postoperative hind foot alignment. It's important not only to correct the ankle deformity, but correct the deformity of the foot underneath the ankle. Okay, so what about valgus angle? So this is almost similar, but different. Interestingly, many valgus ankles still have instability. So you still have to do the ligament work. Many of these patients have a quinus contracture. So you still have to consider Achilles lengthening versus a recession, a gastroc recession. If we're going to cut the calcaneus, well, we're going to shift it the other way. So we're going to medialize it. We still have to think about the medial column in the first ray. It could be a cotton osteotomy, a first tarsal metatarsal arthrodesis, or the dreaded naviculokineiform arthrodesis, which I find always a challenge. But in some cases, the instability is coming from there. The dynamic balancing is in the opposite direction. So we can do a brevis to longest transfer. Don't be afraid to lengthen the fibula. Lengthening the fibula is difficult in a native ankle, but an ankle replacement, when you don't have a polyethylene in there, it's actually quite easy to lengthen the fibula if it's necessary. Hindfoot arthrodesis for large and rigid deformity. And again, once you're in the territory, in the realm of deltoid spring ligament reconstruction, you know you're in trouble and it's a very hard case. So we published this paper looking at associated procedures in valgus deformity. As you can imagine, you need more associated procedures for severe deformity than you do for moderate deformity when addressing valgus ankles. So here's a straightforward valgus ankle. You see the talus is tilted into the tibia. There's a little bit of asymmetric plafond wear of the distal tibia. And this is, you can correct the talus, you can make your cuts. Consider prophylactic fixation of the medial malleolus and valgus ankles, because often that bone is stress shielded. That bone is not receiving as much stress as the lateral side, and that bone may be a little soft. So don't be afraid to put in a prophylactic screw. Now here's a more severe valgus deformity. So we have valgus of the ankle, but we have widening of the syndesmosis and a flat foot. So again, we're going to address the components of the deformity. We're going to do the replacement. We're going to stabilize the syndesmosis, shift the calcaneus, and bring the first ray down. And if you look critically at the first ray with the first tarsomototarsal arthrodesis, you'll see that the first ray is almost a little bit too far down. But I would argue that's okay in this type of case. This is a study that one of our former fellows did at Baltimore, who's many of you know, sees her now at Iowa. He looked at the influence of the first ray on the contact pressure of the ankle and found that the first ray almost has a greater effect on the center of pressure of the ankle than the hind foot alignment does. Now that doesn't mean that the first ray is what you should focus on and you ignore the hind foot alignment. It doesn't have to be either or, it's both. So you consider both when you're addressing these types of deformities. So here's another case of a valgus ankle. You can see that medial malleolus is starting to dip. I'm sorry, the medial shoulder of the talus is starting to dip beneath the medial malleolus. And that's when you know you're in trouble. You can see here, the foot is not too bad. It's not completely collapsed. So there is hope here. There's valgus alignment to the hind foot. And you can see that there is cystic change in the distal tibia. So this has a lot of those challenges we talked about. So we're gonna use a stronger implant to gain support within the bone. So it has a stem. And again, don't be afraid to lengthen the fibula to reestablish that lateral support. But we're also going to do the foot. We're gonna shift the calcaneus medially and do the medial cuneiform osteotomy. Now, what's the role of weight-bearing CTs in all of this? So we looked at this. This was a study that we did. And we said, well, if you look at the foot and ankle offset, which is a way of thinking of the center of the foot underneath the ankle, the foot and ankle offset can be a tool to predict the need for associated procedures. And we found that the foot and ankle offset correlated with our intra-operative decision-making as in terms of associated procedures needed to balance the ankle. And in this studies from the weight-bearing CT group found that the post-operative foot and ankle offset, the post-operative foot alignment may actually correlate with the development of lucencies and cystic change around the implant. So it may be that foot alignment can also affect the long-term outcomes of replacement in terms of a lucency cyst formation and ultimately survivorship. So when you're considering deformity, take a systematic approach, correct the ankle, balance the soft tissues and balance the foot. And when I do these cases, I tell my patients, we're gonna do the ankle and then there's a lot of possibilities. And sometimes I can tell them, well, it's most likely this and less likely that, but everything is on the table to correct the ankle and the foot. And we individualize our approach for each patient based on who they are, their activity level, their deformity, their bone quality, and most importantly, their expectations. Thank you. Thank you. So next we have Pete Mangone. He's going to talk to us about how to manage complications. By the way, if you have any questions, please put it in the Q&A and we will answer them as we go. Pete. Okay. So I'm gonna talk about how to manage some complications. We'll run through some of the things that have been covered. And so we'll run through some of them quickly and I'll try to catch up a little bit. So total ankle arthroplasty, how do you manage complications, right? And I think these are my disclosures, non-conflict with this presentation. I think, you know, so why are you here? Well, a smart person learns from his or her mistakes. A wise person learns from the mistakes of others. So I've done over 400 total ankles, I think in my career, starting all the way back in 2001. So hopefully you can learn from what I've done wrong and the problems that I've had so that you can move forward in a better manner. And I think that's part of why we're here today. So I've divided these into three different phases as to what you can do, preoperative, intraoperative, and postoperative. And Errol's covered some of the preoperative, but we'll just get a couple of different perspectives on that. So Mike Krzyzewski, I was actually at a talk with, there were some others who were also on this call that were at that talk. And somebody asked him, how did he handle the stress of being a coach? How did he handle the stress of these big games? And he was like, well, stress is good, but he said, the way you handle stress is by preparation. Right, you know, if you're prepared, stress becomes a positive thing because it motivates you to do well. If you're unprepared, then stress becomes negative. And so, you know, and the old saying of an ounce of prevention is worth a pound of cure. So like Dr. Bailey said, you know, patient selection expectations is important. Understanding what is causing the problem is important. It can help you predict outcome as well. Your preoperative planning, what type of implant are you going to use? Stem or no stem, flat top tails or resurfacing? What are you going to use for your alignment method? Is he going to use a intra-op external guide? Are you going to use a pre-op CT? Jim Simarco, my fellowship director used to say, clinic is the time for thinking and the OR is the time for doing. And although you make judgments in the OR and you have to, you know, especially build from back to front in many cases, like Constantine talked about, you really want to be thinking really heavily in clinic about, okay, how am I going to do this? What am I seeing? And what am I thinking I'm going to end up doing when I'm in there? Because if you go in kind of blind, you're going to come out with a bad result. Avoid, you know, patient selection. Dr. Bailey talked a lot about this in his talk, so I'm not going to cover that. But what are the things, what are other things pre-op you need to think about? Well, you need to think about your level of experience, right? Do I want to take on this ankle or that ankle? How many have I done? What hospital am I going to operate at? Am I at a surgery center? How much staff experience do they have with a total ankle? We know that time makes a difference. The longer the time in the surgery, the higher risk of complications. So you need to make sure that you've trained your staff, you've talked to your staff, you know what your staff is capable of and what you're capable of, whether you need to stage or not stage in order to have a successful result. You don't just go for gusto. You got to be thinking about these things preoperatively. We talked about a little bit about congruent ankle joints, incongruent ankle joints. What kind of ligament balancing are you going to need? You need to be prepared for that in the OR. You need to have the equipment. What's going on with the knee? Does somebody need to have, if they have an unstable knee, do they need to have their knee replaced first before they have their ankle done? Again, what kind of staging process are you going to do? I personally have gone to anything more than a couple of screws. I don't do at the same time because invariably when I get in there, if somebody's had plates for 20 years, it takes forever to get those out and it is a thrash to do so. So basically, you know, those I don't do in complex foot reconstructions, I don't do at the same time I stage them. Most of the other things I can do at the same time. Alignment-wise, I will tell you that most of the time now, PSI, you know, patient-specific guides are really becoming the standard of care. You can still use external guides successfully, but I think in the next five years, those will disappear. And this will really be the way that things are done, whether whichever company does it. I think the biggest thing that I've found that helps within my assessment is been rotation with these, even more so than varus valgus. It was amazing when I started to see these alignment CTs, the amount of rotational differences in patients and where you put that tibial implant, what their tail or neck looks like, how much varus they're in. Remember, an internally rotated tibia has an externally, the tibia is externally, I'm sorry, if the foot is internally rotated, the tibia is externally rotated compared to the foot. That also helps me plan my incision. And you'll see that in a few minutes. So, you know, to stage or not to stage, I think all of these procedures, if you're a proficient surgeon, can be done in an efficient manner in one surgery. This is based on my first 220 total ankles that had more than four to five years of follow-up. And, you know, I had done, you know, 67 total ankle or Achilles lengthenings, some of which depend on what kind of poly you use, 46 lateral ligament reconstructions, 10 deltoid side done. And I had 44 subtalar fusions done at the same time. But you do have to be careful where you put those screws not to take out the sinus tarsy blood supply. I know that Dr. Di Iorio and the Duke team advised against going top to bottom with screws due to potential for AVN. I have not had an issue with that in my practice. I think part of it is that I keep the sinus tarsy ligaments when I do my subtalar debridement. I use smaller screws and I try to keep the screws posterior to the sinus tarsy area. And with that, I've been able to successfully do that quite well and not had major problems. So you do have to have good technique when you do it. So I think, again, these procedures can all be done at the same time, but you have to identify what you can do and what you can't do. And if you do get into a long case, there's nothing wrong with stopping at that point. Put the ankle in if you feel like you need to do ligament reconstructions, but you just have too much time already. You come back two weeks later when the swelling's better, do a ligament reconstruction, whatever, rather than going another extended period of time if you're not sure what's going on. So if we go to intraoperatively, what can we do to avoid complications? And we'll talk about patient positioning again. I think that has to do with struggling to see, and that goes to not wasting time in the OR. I've found, my personal bias is I've actually gone more lateral than medial with my incision as my career has gone on, and I have fewer and fewer skin complications as I move my incision more lateral. And I think that's really because I can see the joint better without stretching the soft tissues. Handless deeper traction, medial and lateral intraoperative fractures you have to watch for. A gutter clean out is important. Gutter pain after surgery is one of the highest reasons people go back to surgery. I think it's absolutely critical you clean out the gutters. And then I always take the tourniquet down before closure. I've found that when I do that, I just get less post-op swelling, less wound issues, and frankly, the patients don't hurt as much. So here's a good example of positioning. If you look here, I have the knee is straight up, but the ankle is at about 20 to 30 degrees of external rotation. So I really bump the patient up. Sometimes I even use a beanbag and use it as a bump to hold the foot so that the foot, the ankle, the tibia is straight up and down, even though the knee is somewhat internally rotated. And this helps me get to the visualization without really struggling and looking sideways. So don't waste time. We know that intraoperative complicate or post-operative wound complications are directly a result of, or have a high incidence in cases that have higher mean surgical times. So just be aware of that. Don't waste time. Know what you're gonna do before you get in there. My goal is to always have tourniquet time be less than 10 hours, and that's with multiple procedures. If I'm doing multiple procedures at the same time, typically if I do a primary total ankle, I can do it in, you know, I use mainly the inbone system, but I can do it in 55 to 65 minutes on a routine basis. But, you know, when you start, it just takes longer. So just be aware of your time and move quickly. Again, my bias is toward a more lateral incision. I can either dissect between the EDL and the EHL or between the EHL and the anterior tib and then just move laterally with my structures. And again, I think that's lessened my skin complication because I'm not pulling on the skin as much. So, but at the same time, each patient's incision varies. So this patient has a little bit more of a kind of straight up and down incision relative to their ankle anatomy. On the other hand, this patient, if you look from this side view, it looks like it's pretty central. But if you look at the AP view, when I took a picture, you can see how far lateral that incision is because this patient had an incredibly internally rotated foot and ankle complex. She's got a lot of metatarsus adductus. And in order for me to be able to get visualization of that tibia cleanly without really stretching the tissues, that's where I had to make my incision. You can see that little mark on the fibula. That's the tip of the fibula over there, as far externally rotated as that is. So she had a lot of tibial external rotation. Intraoperatively deep handless retraction is key. I use a gelpy retractor. I really try to avoid pulling on the skin as much as I possibly can. Preventing fractures, we talked, both speakers have talked a little bit about prophylactic fixation. I think that's important. I would rather downsize than upsize, in my opinion, for the tibial components so that I don't leave too small of a medial malleolus. You have to be really careful, especially in some of these stiff ankles that you don't lever on either one of the malleoli. And you also have to be very careful, especially as you're cutting these sidebar, your side cuts for your tibial component, that if that bone is very sclerotic and you complete the cut with an osteotome, you can sometimes fracture the posterior aspect if that bone is very sclerotic. So it's a fine line because you don't wanna go too deep or too posterior and potentially injure something. But at the same time, you have to be careful just bluntly using, you know, some of the osteotomes are not the sharpest in the world. If you do identify a fracture intraoperatively, don't ignore it, treat it. You know, don't think, oh, well, I can just leave it there and it'll be fine. I'll just leave the patient not weight bearing. That's not gonna work. Take care of it, treat it. It's just like if you have a fracture of a femur with a tibial, or I'm sorry, a total hip. Again, extensive gutter resections. I am a big gutter resector. I almost always downsize my talus width in order to get more gutter. And I have found that I have had only two patients in my over 400 that I've had to go back to do a gutter debridement on because of pain in those areas. And I really think it allows for better motion. And I think it's a real big source of persistent post-op pain in total ankles and can be handled intraoperatively if you resect those out. Talked a little bit about balancing, making sure, especially for valgus, I found that it's really the foot that you have to correct. As Constanceen said, you really have to make sure if it's not balanced in the OR, it won't be balanced outside the OR. Magic doesn't happen between the time you see it in the OR and the time they get to the PACU. Intraoperative nerve injuries, my experience is SPN is the most common due to excessive traction. If you have a laceration, you can repair it. Oftentimes I will even, there's usually like one very small nerve branch that maybe goes right across the ankle. I will sacrifice that one small branch in order to maintain and decrease my traction on the SPN overall. In the knee, everybody who has a central midline incision, you get that lesser infrapatellar branch. I don't think it causes an issue as long as you take it off right at the truncation of the origin point, but it can be an issue. Post-tertibial nerve laceration, I've had one. Unfortunately, you have to watch down, especially any patients who've had post-trauma, they can have scarred down nerve. I just don't go through the posterior cortex at all with my saw. I thought I was safe on the one that I did, but obviously I didn't. If it happens, I'll be honest with you, you'll be sick in the OR. I was nauseated when I saw it. I had to sit down for about two to three minutes and compose myself. But once you get done, you still gotta get the ankle done. You get the ankle done, you notify the patient, the family, you just be honest with them. You notify your hand surgeon or your microscope, your micro repair surgeon as quickly as you can. Whether they can do it at the time of the case or do it later. And the one patient that I did have where this happened, we were able to get them back in the OR within a week or two. They had nerve cable grafting done. And at this point, she's about two to three years out and has most of her protective cessation back. So, you can have a good outcome if you identify it quickly, but just be honest with people. And if it happens, it happens, and just identify it and move on. Post-op complication, wound management issues, soft tissue ligamentous failure, persistent pain, post-op neuritis, and post-op stress fracture. Wound issues are the most common, obviously. Identify early, aggressively treat, debride early and cover if you can. Sometimes you can wash the eschar, but you have to be careful because if it shows any signs of softening, then you've got to move quickly. And it can be, in my experience, a cause for deeper infection to occur if you wait too long. If it tracks to the prosthesis, you need to wash it out, do a poly exchange, IV antibiotics, and get a plan for wound coverage. Ideally, I know Errol talked about finding a plastic surgeon. My experience is if you're going to do, unless you are in an academic center that has a lot of plastics, then you know the person really well. I would recommend you need to learn how to use wound vats. You need to learn how to cover your own wounds with Integra and other bilaminar grafts, and how to perform split thickness skin grafts. You've got to gut it out and be there with the patient. As soon as you transfer that patient over to somebody else, you better make sure you trust them. Because the last thing you need is that patient to walk into a wound care center or somebody else's office, and they go, oh, my gosh, we've never seen this before. Or, oh, my, that is the worst thing I've ever seen. Or, I can't believe your surgeon did that, because that's a recipe for disaster. And the more you control the message, the more you control the care, the better off I think you'll be, so long as you're competent to do it. You know, here's an example of a patient with wound issues post-op. Eschar, we had to cover it. You can see he actually had no real problem up here initially, but then there it shows up. He ended up with this problem here. Ultimately, I ended up having to resect all this skin here was just unhealthy. And ultimately, with a wound vac, with Integra grafting, split thickness skin grafting, and here he is, his last picture that I took, this actually has tissue over top of it, dermal tissue, and it is slowly healing. And he actually has good function, doesn't have pain, and is back to work right now. But, man, it has been stressful. And I think, you know, but at the same time, if you're going to take on these total ankles, you have to know that these are complex deformities, and these are complicated patients, and especially patients like this patient here who's had, you know, he's had multiple previous incisions. Like Dr. Bailey said, he's had previous, got incisions over here. He's had incisions over here. If you want to take these on, take them on, but have the resources and tools to deal with them. Ligamentous failure, foot alignments, the number one thing, you either have to address it before or after. This is a good example of a patient where I tried to do a total ankle on a patient. You can see just the foot was not corrected enough. And so, she kind of collapsed. The good news is she's about 79. She functions currently in a orthotic. She's happy where she is, but it'll fail long-term. But right now, I think she's going to make it probably through her life with what she has. But ideally, not a great x-ray to look at. Persistent pain, try to identify the locations if they have it. Differential includes infection, infection, infection first, and then aseptic loosening and a different joint. So, this patient, for instance, I saw had two revisions, had an initial procedure, two revisions, and continued pain. A synovial aspiration revealed positive for staph species. And he's going to end up having a fusion, basically. But the other thing you can use is SPECT scans for differential diagnosis in terms of where their pain's coming from. I've found that that works well. Post-op neuritis, you know, it's just a matter of most of these resolved. Just give them time. Stress fracture, if you do have a patient who's done well and they're anywhere from greater than three months to, you know, a couple of years out, they come in, all of a sudden get more swelling and pain, be aware of, you know, they can have a stress fracture develop. Look for a CT or bone scan or SPECT. Fix it surgically as soon as you find it. And look for a cause. Is there some malalignment that's the source? Mainly, you know, as you go forth doing these, there are complications that can occur. You have to be, you have, you're a pioneer and you have to let your patients know that they are relative pioneers. Complications can occur and will occur as we make better outcomes for future patients. So, you know, it's just part of the process. Good luck with preparation. Hopefully you can avoid many of these. However, when they occur, don't hide your head in the sand. Don't pretend they're not there. Identify them. Treat them accordingly. And in general, I've found if I'm there with that patient, you know, going through the process with them, they understand and they will appreciate your candor and willingness to help them get better. And they'll become your greatest advocates afterwards if you help solve their problem. So, thank you very much. Thank you all. Excellent series of talks there. So, if there's any questions, please put them into the question and answer. And we'll address some of those. In the meantime, I'm going to share my screen. I'm going to give the panelists a little case to get their teeth into. So, this is one of my cases. And this is a slightly older gentleman presenting with this deformity. So, who's going to osteotomize this? He's in his, I think he's 84 now. He's requesting a total ankle. He does have some degenerative change in his subtalar joint. He's otherwise healthy. He's out and doing cycling and lives sort of remotely a pretty healthy life. Constantine, what's your thoughts on this? How old did you say he is? 84. Well, it may not be a bad patient to fuse his ankle, Alastair. Okay. So, that's one thing I would do. So, that's option one I would, because, but you know, but the subtalar joint is quite arthritic. So, he has adjacent joint disease. He has deformity. He's 78. So, okay, he's a little younger. You know, I've been doing the osteotomies. I've done them both ways, but I've done them staged. And so, if I need to correct the alignment, I'll do the osteotomy first and then do the replacement second. That's sort of my current preferred way to do it. I think all at once is a bit too much for me personally, even though I do a lot of things at the time of the replacement of the foot and whatnot. There is the concept of splitting the difference. Maybe you can, you know, assess the alignment and say, well, if I look at the proximal tibial alignment and the distal tibial alignment, is there a way for me to split the difference and just get away with an ankle replacement in the lower, in an older, lower demand patient? Maybe that's an option. How will that do long-term? Nobody has really analyzed that and assessed that. And how much does the risk of failure increase? Nobody knows. So, those are the considerations. If you're going to do a replacement, you either split the difference between proximal and distal tibial alignment, in my mind, or you correct the deformity first and then do the replacement second. That's what, those are my thoughts. Okay. I would tend to agree with that. I think also you can probably, when this patient gets into their, if you correct their tibia, I think you're going to find that their forefoot is going to be in significant pronation. And so, I think you're going to have to probably, that would be a good time, if you correct their tibia to neutral, you can actually do their first-ray osteotomy or calc, if they need a calc osteotomy at any point, or you can do those procedures together and that makes your total ankle procedure a little quicker. Because this is not going to be an easy total ankle, either, with the amount of osteophytes they have in that. And they. Errol, any thoughts? You're on mute. Could be the answer to everything, but we can't hear you. Errol, turn your mic on. Yeah. I live an hour from Chattanooga, where Jesse is. So, I'm probably going to ship this over there to Jesse. But, in all seriousness, I'm not playing around with a total ankle in this patient. He's almost 80 years old. I can't really tell what's going on with that talus. It doesn't look like there's much left. I would probably try to do some TCC with, and try to control a little bit of his varus with an osteotomy and a fusion and try to put the longest nail I can up there and see if I can control it that way. This guy sounds like he's a stud. He's been walking around like this for a long time. And I bet if you just get him pentigrade and neutral, he'll probably be okay. That's just my opinion. So, what I did do, here's his CT and he's got reasonable bone on his talus. So what I did was I split the difference and I used a, you know, the zimmer ankle allows you to, those transfibular ankle allows you to put them in a frame and correct things just like Jesse talked about. So as long as the cut in the tibia is pointing up to the knee, and those two angles are 90 degrees, then what happens in between isn't sort of too important. So as long as you've got enough bone to put your tibial component on. So it does require resecting some bone on this side, because you're sort of perching the tibia on the lateral side. But, you know, certainly for somebody like him, we can translate him back by changing your cuts. You can bring him over and then put his foot right under the long axis of his leg and you can shorten up the fibula at the same time. So I've got a few of these knocking around where, just like the principles that Jesse talks about, if you can get the ankle underneath the long axis of the leg, it does take some maneuvering around here with a bimalleal or osteotomy, but that's worked, at least in my hands, reasonably well. Anyway, going on, I'm just going to go back to Pete, why don't we start with your cases here. So you have a case of a 63-year-old patient and former professional hockey goaltender active recurrent ankle sprains. It's not up on the screen there. You're not seeing it? Okay. Excuse me. Here we go. I'll screen share again. Thank you. Actually, do me a favor. Pull the second one up. Pull case two up because I think that's more interesting. That one right there. Yeah. Okay. Here we go. So do you want to just run through this, Pete? Yeah. So this is a 66-year-old. She came in. She'd had a trauma many, many years ago, had very limited range of motion with Aquinas and she was stuck in about 20 degrees of Aquinas through her forefoot and basically had been walking like this for years, had very minimal motion in her ankle, but also has almost no motion in her midfoot at all. And she's hurting. And so had functioned pretty well, but it was getting to the point where she was really hurting a lot. So you can see pretty severe deformity. She's had, you know, she's got terrible arthritis, you know, kind of through her entire foot complex and it's kind of functionally fused that are other locations. So I had, you know, would you fuse or total ankle, you know, concerns about bone, you know, would you do additional procedures? And you know, so that was kind of what I, you know, put on and you can see what I did in a second, but you know, we can see what the panel says. Errol, what do you think? I think with the concomitant joint arthritis and the sub-tailored joint and in the midfoot, I want to try to get some motion at the ankle to help this patient. If you fuse that, then you've essentially got this pan-tailored thing with no midfoot motion at all, and that's just going to be miserable. So I'm thinking, you know, total ankle replacement of some kind. It's a really strange looking talus, it looks sort of like it's really elongated or vertically high. Konstantin, what's your thoughts? No, I agree with Errol's comments. I think this is a challenge because it's a very hypoplastic medial malleolus, it's even a short fibula at that. And if you go back to the other slide, the center of the ankle is not underneath the center of the tibial diaphysis. And so if you're using a stemmed implant, like I know Pete likes to use, you run into a little bit of trouble because if you put the stemmed implant, you're going to be up against the medial cortex of the distal tibia, and that can be a pain generator sometimes. So you have to, again, make some compromises here, and the tibia may be in a little bit of errors. To get this in properly and maybe downsize the talus, you have to basically make gutters because there aren't any gutters. This is, for all intents and purposes, a takedown of an ankle arthrodesis, which is quite a challenging case with a high, high complication rate, the most common of which is malleolar fracture intraoperatively. So, but I think it can be done. Prophecy on that one? Oh, yeah. Yeah. So you can go forward. I can kind of talk about it. Jesse, would you do a total ankle? Yeah, I think I agree with everything that's been said. I mean, I would, but would I regret it? Yeah, maybe. One thing that hasn't been mentioned, first off, I mean, we all agree she's going to do better with a total ankle if it can be successfully done, and I think it can be successfully done. The hard part, like Constantine mentioned, was predicting what are the complications, and she has atrogenic fracture when you're doing, you're going to have to do a super aggressive gutter clean out and realign the mechanical axis intraarticular and translate the talus somewhat. One thing I've done on some of these where it's a super dysmorphic ankle, which is rigid with no mobility, and you have concerns about soft tissue integrity and instability after you've done your debridement, I'll stage it and do an antibiotic spacer, even though it's not infected, but because I anticipate a significant degree of swelling and probably HO, and so you can do all your prep work, do all your debridement, do all your balancing, check your soft tissues, check your tendons, your laxity, put in an antibiotic spacer, let everything calm down, and then go back and your ankle may be more of a chip shot, and this is one I might consider that. Go ahead, go to the next slide. So if you look, one of the things that came up in your op that I want to call attention to is, I really didn't pick up on it until after, was see how little bone she has there. So when I put her stem in, it was definitely looser than I expected, and I ended up having to do some cement with it, but I should have picked that up beforehand, and I didn't, but go ahead and go to the next slide. They did do an in bone, you can see the cement I put around it, Constantine's right, I had to move that prosthesis just a little bit medial than where I'd really like it to be, and I had to go up a pretty good number of stem pieces to get there. I did do kind of a concomitant subtalar fusion, or at least put screws across those areas, did a little preparation in there in the talonavicular joint, had a long OR time, it was two and a half hours of tourniquet time, and you can see, go to the next slide, she did develop a postoperative wound issue, had to do a debridement, and had a little bit of tendon exposed, but was able to get that covered, if you go to the next slide. And then, was able to get that covered, and you can see here, the center view is a video, as well as her walking is a video, if you just click on those, Alistair, they'll, so she's got, you know, some range of motion there, previously she had no range, I mean, almost no range of motion, and at least she's kind of in, she can get to neutral now, if you see her walk, you know, she walks with a fairly, you know, reasonably normal gait now, she used to have, you know, back knee, you know, all the time, because she just couldn't, she was in, you know, an Aquinas position, so she's done very well, x-rays have continued to look good, and she's, you know, had a much better gait, and is very happy with her result, so it was a complicated case, no doubt about it, but it can be done, but definitely has some issues that you have to look for. Awesome, we have some questions on the Q&A, and I think we need to probably address them, so again, for you, Jesse, how are you assessing tibial torsion clinically and radiographically pre-op? Yeah, so, if it's an ankle malunion, or a tibial malunion, you can, it's usually pretty evident within the fibula, and again, but not to be cavalier, you get a full-length CT of the tibia, and the radiologist can measure that for you, I think that patients probably tolerate a little bit more torsion, a few degrees torsion more so, than a lot of these patients, their biggest issues in the coronal plane, varus or valgus, and maybe they compensate some through the hip, but a CT is going to be the most accurate representation. All right, so a question for everybody, it's concerning total ankle arthroplasty and severe cave of varus deformity, do you start with the total ankle, followed by the foot correction, or do you address the foot deformity first, and then do the total ankle? This is a problem, a common, or a difficult one to address for folk, you know, starting their practice, they haven't done a lot, you might consider doing it all at one procedure, but if you don't do it at one procedure, do you do your correction, and then your total ankle, or do you do your total ankle, and then your correction? Errol, what's your thoughts? If I've got significant varus, or significant valgus, and early on, I would definitely two-stage, because I just wasn't comfortable with doing all of it at once, but now with minimally invasive surgery, I can pop a calc slide, and do a TN fusion, and kind of make things happen relatively quickly, but as you were saying, for those who are starting out, I really think to prevent wound problems, it's just better and safe for the patient to correct the foot, and get it where you want it, explain that to them, and then come back, and do your total, because it's just a nightmare when you have all this beautiful bone work, and you're looking at your anterior tibialis tendon, and you can't get any coverage, and then you're getting deep infections, so I'm an advocate for staging things if you're uncomfortable. So you're saying, fusions and correction first, and then come back, do your total ankle second. Yes. But some of your correction might come through your total ankle, so does that challenge you a bit? That's true, and a lot of times you can get a great deal of correction through your total, but I still, with significant deformity, I'm more comfortable staging. Jesse, what's your thoughts? Agreed. If I'm going to stage, I'm typically going to do my osteotomies or fusions first, and do the ankle second. Anytime I do the ankle first, and the osteotomy second, it's usually an oversight, where I should have noticed something when I did the total ankle, and I didn't do it concomitantly. And the other thing, to your point, Hodges taught me years ago, if you anticipate that some degree of your correction is going to come intra-articular, then go ahead and do that with a laminar spreader simultaneously, and start some of the prep work for your total ankle, and place the cement spacer in the gutter immediately. I've had a great deal of patients, the most difficult part is convincing them to come back and get their ankle replacement, because you balance out their foot, and you put cement in their ankle, and their pain is much better. And so, I think that allows you, in that case Pete showed, it allows you to kind of test the soft tissues, and avoid some of that swelling, and go ahead and do the correction, so when you do your ankle arthroplasty, it's much faster, because we were talking about the expedience and the necessity of getting in and out as quickly as possible. Okay. Constantine, how are you advising your fellows as they leave HSS? What do you want them to do, apart from wait a year or so? No, that's right. You know, I think there's no wrong answer, and I think it's okay to try both ways and see which one makes more sense for you. I typically do the ankle first, and the foot, and I try to do it as one surgery. I just saw a patient recently, and I said to him, okay, now time to do the foot, and he goes, nope. And I said, well, what do you mean no? We kind of agreed on this, right? And he goes, no, I don't have any pain. I think I'm going to see this through, and I said, well, that's not the deal we made, you know, and so that can happen to you sometimes when you fix the ankle, and you leave some of the foot for later, and the person doesn't want to come back, so that's a tough one. I really like Jesse's point, and I, you know, we're long right now, so I don't want to belabor it, but I sent in the case of an instance where I did the exact same thing that Jesse just described, putting a cement spacer in the ankle, correcting the tailor tilt, working on the foot, and then coming back and doing the replacement as a second procedure, and at that time, you can also readjust the foot. So if you maybe needed a little more of a heel adjustment or a little more to something, then you can do it at the time of the replacement as part of the second surgery. So I don't think there's a right or wrong answer. Truthfully, you're going to try one way, you're going to try another way, you're going to make some mistakes. You're going to do your best, you're going to be honest with patients, and, you know, find a way. Awesome. I think we should probably thank you all for your excellent presentations and your discussion and helping us all understand better how we should be doing our ankle joint replacements and hand on back to Pete and move on to the next session. So thank you all.

teaching course

ankle arthritis

deformity

osteotomies

joint salvage

total ankle arthroplasty

surgical correction

patient selection

varus deformity

valgus deformity

ankle replacements

severe deformities

total ankle replacement

individualized treatment