When Kristen and I and Glenn were thinking about this area, this is an advanced course. So we wanted to get out of the box a little bit. And as you do more total ankles, you take more risks. And then the more risks you take, the more problems you have. And what we want this section to do is to give you some instruction as to how to deal with complex issues and then how to get the heck out of them when you get in trouble. So our first speaker is Elizabeth Cody, and she is from Hospital for Special Surgery, did her fellowship at Duke, as did our other two speakers other than myself. I trained at HSS myself, so this is kind of a HSS Duke session here. So I'm gonna turn this over to Elizabeth. Elizabeth, are you there? Yes, I am, thank you. So should I share my screen and do it off my side? Yeah, hit the share screen and then. Okay. All right, so my topic is a mammoth topic, deformity, cysts and bone loss, what do I do? So my disclosure is I'm a paid consultant for Stryker. Probably more importantly, I trained with these guys at Duke, like Errol mentioned. I think I'm in good company though. I think pretty much everyone else on this panel also trained at Duke. So deformity, cysts and bone loss, in other words, these are very challenging total ankles. What I'll just emphasize before starting is that for a lot of these cases, there aren't really any right answers. I think that you're really trying to do the best that you can for each patient with very limited evidence. So you're doing what works for you, what's worked in your experience, and that may be different things for different surgeons. So I'll be going over some interesting cases that I've had that kind of reflect some of these principles and some of the difficulties of these cases. And hopefully that will be a little illustrative. So in my experience, success really lies in being fully prepared for these cases. You make sure you have the right implants, all the potential backups you might need, and just really take a lot of time to really think through these cases before you do them. Really thoughtfully examine the patient, think about all the things you might have to do. I think it's also extremely important to adjust patient expectations. For these difficult cases, patients really need to know that these are difficult cases, that there's a decent chance there'll be additional procedures that you have to do during the surgery in addition to the ankle, which could prolong the recovery and increase the risk. There's a higher risk for revision with these cases. They may need to be converted to a fusion in the future. They should all be very well aware of the risks associated with these procedures that are probably higher than doing something like a fusion. So to start with deformity. So there are now multiple papers that we have showing that big deformity is not a contraindication for total ankle arthroplasty. So these patients may require more procedures at the same time, but they're not necessarily a higher risk for failure and they won't necessarily have worse outcomes. So principles of total ankle arthroplasty and big deformities. I think it's very important to try to correct the deformity before attaching your cutting guides. So you need to make sure that you do any soft tissue releases that you need, you know, any osteophytes or address any bony alignment that may be blocking the correction of the alignment. And then you'll do your best to correct the deformity with the ankle. And then once the total ankle is in, you assess the need for any other procedures that you might need for stabilization or to realign the foot. So these can be very long, stressful cases. You wanna make sure you're prepared for everything. So make sure that everything you might possibly need called in. Increased surgery time for these cases does mean increased risk. So you really have to think about whether you'll be able to get everything done that you need to in these cases. And in some cases you may want to stage them because it's just too much to do all at one time. It's just too risky. So in cases where I really am trying to do a lot, I make sure that all of those patients get a Foley. They'll get ibuprofen amic acid at the start of the case. I'll do the total ankle first. And then once the total ankle is in, I kind of reevaluate to see what else I think has to be done. At that point, if I do need to do other procedures and I don't think I'll have the tourniquet time, I close the ankle joint first. I do think that potentially could decrease the risk for infection. So I'll put vancomycin powder in the joint. I close the capsule, I close the retinaculum, and then I'll let down the tourniquet while I close the ankle incision. So that usually gives me like 15 or 20 minutes where I can have the tourniquet down and then I'll reinflate it to do the other procedures. Of course, there is the risk with this that you have to go back and do something in the ankle. Fortunately, I have not had that experience frequently. So this is an example of a big coronal plane deformity. This is a 30 degree varus deformity. So you might wonder why not just fuse this patient with that big a deformity and he still has a subtalar joint. Well, he's a 71 year old male. He's very trim. He's healthy. He's a non-smoker. And he really has good ankle motion. He has like 40 degrees of ankle motion. So that's somebody who would really miss that motion if you fuse them. And he really wants to return to hiking, which I think is hard with effusion. So principles of varus total ankle arthroplasty. These patients, unlike the patient I mentioned, are often very stiff and it's often difficult to fully correct the deformity. In these cases, I will always try to position the implant in slight valgus to avoid medial malleolus stress fractures, since I think the primary risk factor for those fractures is having the implant in slight varus. So this is an example of an intraoperative floral shot showing how you can't be distracted by the joint surface. So if you're just looking at the joint surface here, it'd be very easy to position that implant in varus. So you have to be very careful that you're really aligning yourself with the shaft and you're going to adequately correct the deformity through the tibial cut. And again, aiming for slight valgus. And I'll usually under resect the tibia if there's laxity in the joint. You especially don't want to elevate the joint line. So in a case like this, where it looks like there's some medial bone loss, you're gonna be extra careful about that. This is his postoperative X-ray. And then one year later, you can see his good alignment. He had previously had the calcaneal osteotomy and the first metatarsal osteotomy. So actually, once I did the total ankle, I found I did not have to do anything else. So that was a nice, pleasant surprise. Valgus total ankles. These are often more challenging than varus total ankles. They're more likely to fail than varus total ankles. These patients often have laxity in the joint. So again, I will usually under resect the tibia. And I'll just note that valgus ankles secondary to instability are a very different entity from valgus ankles secondary to a longstanding flat foot deformity. Patients who just have a valgus ankle from instability, often you're just doing the total ankle and it can be quite a simple surgery versus valgus secondary to longstanding flat foot. You really need to comprehensively correct their flat foot almost all the time in those cases, in addition to doing the ankle replacement. So what I was hinting at is basically that valgus arthritis secondary to the progressive collapsing foot deformity, I really think this is like the most challenging problem that we deal with. It's extremely difficult. This is an example of a patient I had with bilateral deformities, relatively young guy around 60, very, he did lots of sports his whole life and comes in with these horrible ankles. You can see his feet here. And then the lateral views, you see really severe flat foot deformity. So typically my approach to these bad cases, I'll first correct the foot and then I'll come back later for the ankle. So in this case, I did a subtalar fusion. I did a percutaneous medializing calcaneal osteotomy for additional correction of the hind foot valgus. I did a first TMT fusion to try to bring down the first right. And then I did a gastroc recession. Then a year later, I came back and did the total ankle. So you can see, I chose a stem implant. I think that's important for these cases with bigger deformities, especially where you're doing a hind foot fusion. I did a revision medializing calcaneal osteotomy to further bring the heel over. And then there was residual medial column instability with supination. So I did an NC joint fusion with allograft interposition to again, kind of help bring down that first ray. So he's only three months postoperative. That's all I have so far, but so far so good. Of course, you look at these x-rays and you can see that valgus tailor tilt on the AP view. So of course I worry a ton about these cases. If I wonder if he's going to be okay. And I wonder about all the other possible things I could or should have done. And this just highlights how little we have to guide us as far as what the right thing to do is for these index surgeries. So should I have lengthened the fibula? You can see the fibula looks quite short. Maybe if I'd lengthened the fibula that would help prevent him falling back into valgus. Should I have done a deltoid reconstruction? I didn't think that he needed it at the time of the surgery. I thought he felt pretty stable, but maybe having something stronger immediately would have helped. Should I have done a peroneus brevis to longus transfer? So there's all these things, all these ways you can second guess yourself about what you should have done. Then of course, this is another patient where I did a very similar surgery about three years ago and following him very closely because you can see this valgus tailor tilt, but he's just delighted with his outcome. He's even like playing some pickleball. He's just super happy. And I think the functional outcome that he has far surpasses what he would have gotten with a fusion. So even though we look at the sex ray and think it's not perfect, it's hard to argue with his outcome. And then for some of these big deformity cases, you might think about taking the easy way out and using patient-specific guides to correct your deformity. But I would caution you just that you still have to achieve soft tissue balance, and sometimes it may be too aggressive a bony correction. You may find that the ankle won't want to move as much as the sleek preoperative planning planned out. So in my experience with these bigger deformities, I do think I find it easier to balance things if I do it myself with the standard instrumentation. Moving on to cysts. So if any suspicion persists on x-rays, I always get a CT scan. I don't routinely get CT scans, but if there's even a hint of a cyst, I will get one. And you'll find the most problematic cysts are in the talus, and can usually be managed with either bone grafting, if there's still enough structural support for the implant, or just using a flat cut talus to bypass the cysts. If the cyst is large enough, you may have to do a bone grafting procedure, wait for it to incorporate, and then return later for the total ankle. So this is a case where you can see there are some clear subchondral cysts. This is a patient with hemochromatosis. So I got the CT scan. So you can see pretty typical, but on the larger side, subchondral cysts. This is an example of a case where I was able to just do a flat cut talus to bypass the cysts in the talus, and then was able to use a very standard implant. So this worked out well. This is an example where I got a CT scan to look at the medial bone loss, and then saw this large cyst in the medial malleolus. So you can see there's a lot of bone loss in the medial tibial plafond, but then you do also have this really large cyst, which I thought needed to be treated. So my plan was to treat that cyst with bone grafting, and then adjust my tibial cut to compensate for the medial joint loss, and relatively under resect to prevent joint line elevation. So this is the intraoperative x-ray from that case. So I was able to make a small window into the cyst with a curette, and then use graft from the tibial bone cut. And that's one really nice thing about total ankles. You always have this substantial tibial bone cut that is useful for bone graft. It's also useful for instance, if you have to do a cotton osteotomy, or you want to do like a first TMT fusion with a dorsal wedge for plantar flexion, you can always fashion that wedge yourself from the tibial cut. And then it may be as a higher chance for healing than an allograft. This is another case with much more pronounced cysts. It's a little bit more atypical. Not often that you would see something like this, but this is a nurse in his 20s with hemophilia, who had had recurrent hemarthrosis in his ankle, and over time developed these really quite large cysts. And it got to the point where when he saw me, he really couldn't put weight on his ankle at all. These are his CT scan slices. You can see expansile cysts in both the tibia and the talus, basically filling the whole talus. So thinking about this case, I thought there are two pretty viable options. One is to bone graft the cysts, infuse him, or bone graft and maybe do a total ankle replacement later. I didn't think a total ankle replacement was an option at this time. So what I did is I used a synthetic graft material to graft both cysts. There was a small window in the anterior tailor neck through which I could get into the tailor cyst. And then I made a little window in the anterior tibia to get into the tibial cyst. So I was able to debride and graft both cysts through windows outside of the joint. And I used a radio-dense graft, calcium phosphate and calcium sulfate. And then you can see he did really well. So he was non-weight-bearing for six weeks. By 12 weeks, he was walking pain-free in sneakers. And at six months, he's back at work and really happy. These are his six-month post-operative CT scan slices. So you can see the graft actually did incorporate pretty well. You know, I wouldn't say it's perfect, but I do think it's good enough where a total ankle replacement is now an option for him, even though he's doing well enough at this relatively short-term follow-up that I don't think he needs anything for the time being. Moving on to bone loss. So with bone loss, you can usually compensate for small amounts like mentioned in some of the previous cases with bone cut adjustments or implant adjustments like using revision implants. You have to have the malleoli. So even though I know you can do fancy things with custom implants, in my opinion, I think that no medial or lateral malleolus means you have to do a fusion. Bone loss on the talar side, it can be treated with a revision talar component or if there's really enough bone loss, a total talus replacement. And bigger defects can require creative solutions, just like some of the other cases we've talked about. So this is an interesting case that I dealt with recently. So this is a relatively young patient in his 50s who developed this really severe varus ankle arthritis over time. And you can see this really severe flattening and basically loss of the medial malleolus. These are his standing hip to ankle films. You can see he also has knee varus. So this was really challenging and I spent a lot of time thinking about and talking to colleagues about what the right thing to do was. These are his CT scan slices. You can really see the flattening of that medial malleolus well here. You can see how basically that medial malleolus is not really doing anything to contain the talus there. So this would be a problem just trying to do an ankle replacement because that talus wouldn't be contained under the medial malleolus. And of course the patient didn't want a fusion. So what I ended up doing, you can see something very aggressive. So I did a distal tibia dome osteotomy. So you can see the dome osteotomy here. And I ended up actually booking it open a little bit here and filling it with some graft. And then laterally I did a distal fibula osteotomy with some shortening and bringing it into valgus. And then I also did a separate medial malleolus opening wedge osteotomy that I filled with iliac crest concellus autograft. So this was a huge surgery. I mean, he had three very large incisions around the ankle. So I basically got what I deserved and this is him two months post-op. You can see he got this big wound on the front of his ankle but fortunately that healed with wound care. And then six months post-op, he was fully healed on CT scan but he was still having a lot of ankle pain. So now he can get a total ankle replacement. The question is, did we really save him all that much because he's very stiff and ultimately his motion may not be much better than a fusion, but overall his alignment is much better. You know, I still think something was accomplished here. So in conclusion, these are really challenging cases. You have to proceed with caution, be really thoughtful, spend a lot of time thinking about and doing these cases. These are good cases to do just one or two on one day. There's not a lot of evidence to guide decision-making so you have to use your experience and also I think using colleagues is really helpful. I'm always surprised with these cases how many different opinions I'll get for things that you could do. And I think, you know, there's not really a right answer so you have to pick what the right answer is for you. And unique cases can require creative solutions which is part of what makes our job so interesting. Thank you. Thank you. You can unshare and then we will move forward. That was fantastic. I see those kinds of things all the time and I just flat out don't know what to do with them half the time. That was very good. We've already generated some questions which we will entertain at the end of the session. Let's see. I am next. Okay. You saw Elizabeth get a wound complication from multiple incisions. Well, we have to deal with this with our total ankle replacements as well. And I want to talk to you about some ways to try to stay out of trouble although invariably it's always going to happen. Let's see. I'm trying to get mine to move here. Okay. These are my disclosures. So as a foot and ankle surgeon the main thing we don't want to do of course is shoot ourselves in the foot. However, if you do enough total ankles invariably you're going to have this issue and you're going to be asking yourself how in the heck did this wound happen? How did I get here? Well, to help with this discussion I just want to talk about total ankle incisions in general. And what I want to focus on is one, two and three because that's what we most commonly do particularly number one. And although there are transfibular lateral approaches and posterior approaches that's not something that we commonly do. So this is what we typically do. The anterior incision interval between the anterior tibialis and the EHL. Some of us opened up the anterior tibialis sheath. Some of us don't. We go right down the bone sweeping the rest of the bundle laterally and the exposure is fantastic. But how do these do really? Here's a study with my rev and higher and I want you to focus on just what is in bold. They had 300 patients and they compared fusions to TARs. But look, that's almost a 20% delayed wound healing greater than 30 days. Okay, there were no differences in outcomes between the fusions and the TARs but I just, for the sake of this talk want to note approximately 20% delayed wound healing. Same with this study, Raken, JBGS 2010, 106 TARs. If you combine minor and major wounds you're looking at a 33% wound complication. And what they found in this study is that if you had rheumatoid arthritis the chances of getting a wound problem were even greater almost up to 14%. And I found that to be true in my practice. Here's another, Whalen 2010, 57 TARs, wound breakdown, 28%. And most of these people are somewhat sick. Many of them smoke, most of them have some peripheral vascular disease and some cardiovascular disease. And those were found to be significant risks. So the bottom line is most likely the more of these that you do, the more trouble you're going to ultimately have. And the more complicated the case, the more complications with the skin that you're gonna have. Here's the Gross and Nunley study out of Duke that showed that if you take a long time during these cases and Elizabeth talked about how she likes to let the tourniquet down and close the anterior wound. If your surgery is extended by more than 26 minutes or so by doing multiple different things during the case, those are the people that had significant wound problems. And also another interesting point was that in this study, the time to operatively treat these wounds was almost two months. So what that kind of shows is that we tend to sit and watch them and then hope that they get better and then ultimately they may end up in a bad place. And why does this happen to us? Well, it's because our burden is different from our sports docs or our hand partners or our other total joint partners. We don't have a big soft tissue envelope. We just don't. And so our burden is greater. And if you looked at this particular study, you'll see that superficial soft tissue infections in the ankle, our rate of problems is just far greater than those of our partners. So our burden as foot and ankle surgeons is just more difficult to begin with. So what are some other ways then where we can try to minimize these complications that we know are going to happen? The Daniels paper in November looked at the extensile anteromedial approach. You see this curvilinear incision, the interval that he uses is still the same between the EHL and the anterior tibialis tendon and the joint exposure is fantastic. Well, why is that? This is based on the angiosome understanding and angiosomes are three-dimensional blocks of tissue supplied by an underlying artery. And there are six angiosomes in the ankle actually. And basically his approach is that if you respect the angiosomes and spare the blood supply that you're gonna get a better result. How those patients do, there were 73 patients. And if you talk to Tim, he'll say that he's had some mild superficial wound problems but nothing deep. And this is his preferred method for all total ankles. I've been doing more of a modified lateral approach. And this is an interesting article and for neck orthopedics in 2021. And what's interesting about this is this incision is slightly more lateral. And when you close this wound, you can see that you have way more extensive retinaculum to close. The interval is between the EHL and the EDL. So what's interesting about this is you don't ever see the Tib Ant, which is a nice thing if you do get wound breakdown. I want to point you to section B here. So this is the interval that I use between the EHL and the EDL. And I simply swing the EDL laterally and the bundle laterally as you would do with the standard anterior approach. Here's the exposure and you have great retinaculum to close. The one pearl here is the superficial peroneal nerve comes in slightly in a different orientation than you're used to. You got to be real careful and identify it before you start doing the rest of your dissection. How'd those do? Well, some of those got eschar and I still get some superficial wound breakdown, but I never see the anterior Tib in my wounds. I might see a little bit of the extensor didge, but I never see the anterior Tib Atlas. And I believe it's because of a better, faster closure that you get. The exposure is as good as with the standard approach. So when you have these wounds, what do you get? Well, there's a wide variety of superficial and deep problems that we will encounter. But once the wound goes dark or there's abundant tendon showing, we know we're in trouble. What to do? Many of us will pass the buck. Some of us send patients to what I call the haunted house, which is a wound care center. Some of us punt it to a plastic surgeon and some groups are lucky enough to have a plastic surgeon in the group that can actually take over. And that surgeon actually understands the urgency of getting this wound closed. I don't. So I don't pass the buck. I try to treat these myself. So I say not so fast to transfer in these patients. Why? Because I've established a relationship with them. They trust me. They want me to do it and they don't like going other places. And second, most of the other treating doctors don't understand the urgency of getting that wound closed. So we're dealing with this situation. The patient's looking at you asking, you know, why did this happen to me? And then as the surgeon, you want to ask yourself the same thing. Why is this happening to me? Who is the enemy here? Why is this happening? I did a perfect surgery. Why is this falling apart? Enemy number one, you. So in my many cases, the enemy has been me. I stayed in the case too long. I tried to combine multiple things and I just shouldn't have. So in the words of Clint Eastwood in one of my favorite movies, a man has got to know his limitations. Know what you can do. Know what rate you can do it. And if you have to two-stage things like Elizabeth showed, that's absolutely fine, but simply don't be in there too long. Nunley studies showed you that the longer you're there, the greater chance of having a problem. Sometimes the enemy is the patient. Oftentimes it's the patient. Multiple train track wounds, cardiovascular disease, PVD. They say they don't smoke and then they actually do. So you always want to check for nicotine levels in people who you suspect smoking. Rheumatoid disease, lupus, mixed connective tissues disorders, diabetes, obesity. All of these things tend to lead to problems and you have to be beware and take this into account when you're planning your incisions and what you're doing to treat these patients. And the third thing is the skin. The skin is the largest organ in the body. It's under constant repair. So when there is a wound problem, it just totally gets revved up. It's working overtime and extra hard and it gets stressed and things go wrong. So you have to be aware of the skin itself. What's going on? Well, what's happening is biofilm is forming, which is the definite enemy. It's that white slimy extracellular matrix layer that you see in the wounds, which is why you do wound to breed marks. It blocks immune cells. It blocks antibodies getting to the wound and it flat out just stops the wound for healing. And even if you clean it out within 24 hours, it's back. So the key is to get rid of biofilm to help your wounds progress. And I'll show you some things that I do. So now I get to air out my dirty laundry and I've got some out here. Anyone who does a number of these cases, they also do as well. Case number one, the enemy was me, okay? But I thought I could help this patient. Ultimately, I ended up helping her and she loved me, but it wasn't without some costs. 72-year-old, ankle fusion, had sub-tailored degenerative arthritis. I'd given her some cortisone shots for a few years and it had worked, but now she had excruciating pain and couldn't walk and really didn't want her leg anymore. And she'd been to a few other doctors. They talked about sub-tailored fusions. And we all know that these are difficult to get to happen under an ankle fusion. So I offered her something else and I told her we could always do an amputation, but let's try to do something else. So here are the incisions that she had. You can see the curvilinear anterior incision she has, and there's a fibula incision. I did a fusion takedown and then everything was going well. And then I broke the medial mouth. And because I had my stem in, I couldn't just put screws in confidently because whenever you do one of these, the bone is soft and I wanted to be able to walk this patient. So I had to plate her. What did that do? That extended my OR time. There was the incision I used, which looked fine. I connected what she had and extended it. Two-layer closure because her skin was thin. And there I put an amniotic skin graft, which I always do subcutaneously. Here's her incision. She did have bleeding through her splint. She came back post-op day one. I changed it. And then I saw her again at five days. She looked like this. I thought I was going to be okay. But at 21 days, I know I'm in trouble. I'm going to need something else done. Radiograph release, she looked fine, but I'm scared. Here's the subsequent wound breakdown that started to happen over time. Further breakdown as I cleaned the wound with the anterior tibialis tendon exposed. So I know I'm in trouble. And then in the words of a recently deceased rapper, I'm about to lose my mind in here because this is what she looks like and I don't want to take this leg. So I used a substance called Curiply. I know we're not supposed to use trade names, but this is the only substance that has the ability to reduce biofilm in the wound. And then I followed that with a skin substitute. This Curiply has PHMB in it. It disrupts bowel burden and it actually acts as a bridge in the wound so that you can put this in the wound after you've done an IND and leave it for a week. You don't have to see the patient back. It's antimicrobial and it prevents biofilm formation. And of course I used a skin substitute later after I got granulation, a skin substitute that has fibroblasts in it and human keratinocytes. And that was the particular one that I used which looks pretty much like skin. So weekly care, she came back. I kept debriding. I kept adding the skin substitute and debriding. Here at about three months, I had some healthy granulation tissue. The wound began to shrink with the skin substitute and weekly debride months. And at five months without the use of a wound vac, I was able to get this closed and I got her from this to this. Now it took five months, but the lady came every week. She was compliant and we got this done. She loves me. She's doing well and she's happy to have some motion. Case two, I am not the enemy on this one. This is a rheumatoid arthritis patient with methotrexate that we took off before we did a surgery. Ex-smoker, dinner, anterior approach, amniotic membrane. And then one month because of RA, she started breaking down. I took her for an IND, added a negative pressure vac, and I started doing local care, added the skin substitute with the wound vac. You put this on, you put adaptic over it. You make sure it's adhered to the skin with the SteriStrips, the wound vac, weekly care. She started to granulate in. Once I get it here, I put the longitudinal slits in the tendon and you'll see that it'll bleed and you know you have granulation tissue below. Here, I used a bi-layer synthetic skin graft that I put on top, sutured it in. And then later she started to granulate. She looked like this. It was taking its time. So I did reach out to my plastic surgery person for a splinted skin graft because I don't know how to do that. It's an intern case, something that I used to do as an intern, but I've just lost that skillset. And slowly she went from that to here. And then, so this was the beginning and that's where we ended. Case three, 73-year-old female. And I ain't the enemy here either. I did a simple uncomplicated TAR with a flat cut talus. She went home and she fell and fractured her medial malleolus. Lo and behold, when I took the splint off, she had a dehistor wound. Here you can see that anterolateral approach. So even though I used this modified anterolateral approach, I did have an issue, but I'll tell you what was great about it. I took her back to the operating room and did a wound abreatment. There you can see in the center, my deep fascia is closed and there's no exposed tendon. If this was a standard anterior medial approach, I'd been looking at the anterior tibialis tendon, I guarantee you. But with this approach, I did an IND through a separate medial incision, plated her medial malfracture so that I could walk her sooner. Wound vac at the time, there she is at one week. There she is shortly thereafter. And I'm putting on the PureApply, again, steristripping it, and I'm using a vac on top of this. When they come back, they look like this on the left, and then they progress. You can see her in the center, and then you can see me using the skin substitute on the far right. And then over the course of three months, I got her here. So I got her from here to this. So it's possible, even with massive amounts of exposed tendon, to get this done. What else? In closing, I just wanna say negative pressure does work. I use this in very complicated patients with RA or someone that I'm really worried about. This paper says that it does work. They had 100% incisional healing. I don't know about that, but it does work, and I will use it. There's no reason not to sprinkle vancomycin in the wound. At $5 per 1,000 milligrams, it's cheap. And particularly in diabetics, it clearly reduces the incidence of superficial skin infections. So there's no reason to not do that. And I always use amniotic tissue subcutaneously. There's literature here and also articles by Steven Newfield to show that it reduces dehiscence. Other studies, Schipper and Haddad showed that compression works, and that's basically what the back is doing when you use it. It's just sucking out all the edema. PRP does not add anything to reducing wound healing. So in closing, what do I do? Multiple incisions, you're at risk. If you need two or more procedures, you're at risk. Cardiovascular disease, smokers, inflammatory disease, this is all scary. So what I try to do, if I've got a routine patient without significant issues, for me, I will use my modified anterior lateral incision. I always use vancomycin, and I will always use amniotic membrane subcutaneously. If I'm worried, connected tissue disease, multiple skin incisions, big varus or valgus deformity is gonna take considerable time. I will use patient-specific incision, vancomycin, amniotic membrane, and I will just add a wound back in the operating room at that time. As Elizabeth talked about, if you're gonna do something significant like on a flat foot, do that first, and then I'll come back and do the total ankle later to save time. So this pretty much says what I just said, skin breakdown on the left. If you just have a swelling, elevate it and watch it. If you've got full thickness loss, you can treat this with the wound care matrix. If you've got tendons exposed, you can also get away with treating this with wound care. However, if you've got infected hardware and you've got to go deep, take it out and then close your wound and they may need a flap. Also, some consider flapping patients first when you have significant skin problems and patients are persistent about needing a total ankle. A real quick thing here, I hope this doesn't make people uncomfortable, but this just shows that you can get paid for your work in your office doing this wound care. Most companies will require four weeks of wound care, the insurance companies. Medicare does not. You can start day one once you get that approved. You also have to use a venous stasis or diabetic ulcer code. Most of these patients have swelling and venous stasis, so I feel comfortable using that code. Synthetic grafts cost about $1,200. Medicare will pay 160 for the wound or bleed mark and 1,300 or so for the graft. So there's about a $250 profit there for your work and keeping your patients close to you. And commercial insurance will pay in the area of 2,500 for this graft. So there is a marketable or a more significant profit there, plus the procedure code. So you're keeping these patients close to you. They want you to do their care, and it's also somewhat profitable for you at the same time. So incisions do matter. Know your limitations. Don't be a hero. Avoid long cases. Find an incision that works for you. And I think you should do something. Vancomycin, amnio, wound vac, something. And then when you get in trouble, make sure that you have a good relationship with a plastic surgeon that you can use when you need to. Thank you. So let's move on to our next speaker. Are you loaded up? I am just getting my screen share. This is Dr. Kadakia from the Emory Clinic. He's also a Duke fellow. And we have the pleasure of having Dr. Kadakia in town. I'm also from Atlanta, a very local, very well-respected orthopedic surgeon, foot and ankle specialist. So we'll turn it over to him. Awesome, thank you. Thanks for having me. I'm gonna talk a little bit about infection, fall and ankle replacements. And I'll start this talk with a few cases. These are my disclosures. So case one, this is a 65-year-old gentleman, longstanding history of right ankle pain. He's failed conservative care. Otherwise healthy, doesn't smoke, decides to undergo an ankle replacement. Does great intra-op, no complications. These are his final intra-op images. Everyone's really happy with this. Comes in at your two-week appointment, no issues. His incision looks pretty good. He takes his sutures out and he goes into a boot. About a week or two later, he calls your office, starts saying, hey, I'm having some pain, swelling, some warmth, and there might be some drainage from his incision. So bring him into the office, got elevated inflammatory markers, worsening pain, warmth, and now there's drainage from the sinus tract. So we'll come back to this. So case two, this is a total ankle performed at an outside facility a couple of months ago. Post-operatively had some wound complications, dehiscence, persistent drainage. There's elevated inflammatory markers. You don't really know much else yet. He's referred to your center just because there isn't a plastic surgeon at their hospital. So these are the images that are uploaded to your system. Bring him into the office, take his dressing down, and this is what you see. So, you know, now that you know that these ankle replacements are likely infected, the question becomes what to do now. So we'll go over a little bit about the background, the diagnosis of infection, fallen ankle replacement. We'll talk a little bit about the options that are available, what makes sense. You know, what are some of the considerations for management of these patients? We'll review some of the outcomes in the literature. You know, we'll find that there's really not that much out there on this, and we'll come back to these cases at the end of the talk. So the reported rates of infection after ankle replacements is about 4% in the literature. You know, this can vary depending upon the study that you cite. There's really no consensus guidelines or high-powered studies to guide the definition or even the management of infections in total ankles. Most of what we really know and use is based on hip and knee replacements. And, you know, it's important to note, is this truly the same thing? You know, the vascularity, the soft tissue envelope around the ankle is very different from that in the hip and the knee. So in 2019, there was a consensus work group that got together, published a series of guidelines on infections following ankle replacements. And one of their findings was there's really no data to support how we diagnose infections in ankle replacements or even define this. This is a scary thought to consider because the consequences of this are pretty dire for the patient and for the surgeon themselves. Most of us are pretty familiar with this. This is the MSIS criteria from 2013 that our joints colleagues used to diagnose infection bone, hip and knee replacements. It's important to note that this has been updated. So this is the most recent diagnostic algorithm available for hip and knee infections from 2018. It consists of two major criteria that have stayed the same and a variety of minor criteria and also this category of possibly infected and also intra-op findings as well. And this is what I would recommend using and having at hand when you're trying to diagnose infection after ankle replacements. So let's say you've established the diagnosis. You know, the first big decision to make and conversation to have with the patient is about salvage versus amputation. You know, in most cases, salvage is reasonable. It's what you would aim for, but it's important to have an honest and frank conversation with the patient about the problem that they have and even present amputation as an option. You know, there are some patients in which an amputation just makes more sense and we'll dive into that here in a minute. Once you've decided that salvage is the route you want to go with the patient, the next step is some pre-op workup optimization and then also determining the chronicity of the infection because that's going to help kind of guide the surgical options and whether you're going to go down a one-stage revision or a two-stage salvage attempt. So one of the first questions to ask really is, you know, why did this happen? Are there patient-specific risk factors that can be controlled or reversed? Is there an infection history? So an infection somewhere else that's seeded the ankle joint, you know, history of previous infection in the ankle. If there's any question of a sinus tract or a wound, I typically always involve my plastic surgery colleagues. Any question about perfusion warrants a vascular surgery evaluation. You know, if they don't have a good soft tissue envelope or poor perfusion, salvage just isn't going to work. It's also important to ask the patient what their functional goals are. You know, a lot of these patients have had 17, 18 surgeries. Do they just want one surgery that'll get them pain-free, that carries the highest chance of success? Are they okay with a prosthetic limb? You know, these are the questions and steps you have to take in these kinds of situations because it might help point to whether salvage is a good idea or not. And if they were a high risk for infection with their primary replacement, you know, salvage is probably going to carry the same risks if you can't control some of those factors. So the next step is determining the chronicity of the infection. In the total HIPAA need literature, this is defined at 90 days. There is some variability on this within ankle arthroplasty literature, and most studies kind of point to four weeks. But it's important to note, is chronicity the only thing that you have to consider, you know, when you're debating between a one-stage or two-stage salvage attempt? At a 2019 work group, I looked at this as well and identified that there's other factors you need to consider with regards to ankle arthroplasty, such as patient-specific factors, you know, bone loss, deformity, the type of organism that has infected the joint before deciding if they're good candidates for a one-stage revision. So kind of coming back to our chart here, you know, there might be some stuff that comes up in your pre-op workup optimization, especially if you've never met the patient or didn't do their primary, that might make you think or might point to the fact that amputation just might be the right option for them. And chronicity, while important, isn't the only thing to consider when determining if they're good candidates for a one-stage or a two-stage salvage attempt. So looking at indications for one-stage revision, you know, these are acute infections, for me, less than four weeks, good hosts, no significant past medical history, good perfusion, adequate soft tissue envelope, no significant deformity or bone loss noted, and also organisms that are not resistant to multiple antibiotics and can be treated well with a good IV regimen. For one-stage revision, you know, you need a thorough irrigation, debridement, deep soft tissue cultures. I always aspirate fluid. If it wasn't done in the clinic, I'll do an intra-op before we start to have a good sample to determine what organisms might be involved. Careful soft tissue management involving plastic surgery if you need them, targeted antibiotics, kind of close monitoring of the inflammatory markers post-operatively in the wound, and I keep these patients off of this until this wound is completely healed. Again, the soft tissues are crucial for this to help prevent infection. For a two-stage salvage attempt, the first stage involves removing all of the components. Again, a thorough debridement of both the bone and the soft tissue. In some cases, I'll use a saw and make some new bone cuts just to remove any of the bone that appears unhealthy or necrotic. Deep soft tissue cultures of both soft tissue and bone. There's really no literature on this with regards to whether you need pulse or cystotubing for irrigation. I like using cystotubing, but there's not really any literature to support either. And for the antibiotic cement spacer, I'll put vancomycin and Tobra, and the concentrations depend on the cement you use. With regards to antibiotic timing and management, I always involve the infectious disease team in determining this. For a one-stage revision, completing the full six- to eight-week course, trending the inflammatory markers. If there's any concerns with the wound or their inflammatory markers or repeat aspiration is typically what I'll do. For a two-stage case, again, completing the six- to eight-week course of antibiotics. And then with regards to moving on to stage two, I'll always have some type of antibiotic holiday. The literature recommends anywhere from two to eight weeks. I use six weeks. And for the DSR-CRP, again, make sure these have normalized. In some high-risk cases, a repeat aspiration before moving on to stage two isn't a bad idea. Again, there's no literature on this, but getting some samples to confirm that the infection has been cleared is not a bad idea to move on. So let's say in a two-stage salvage, you know, the wounds have healed, infection's cleared, you've kind of met all of the check boxes to move on to stage two. What are your options here? There's a lot of options to consider. There's revision ankle replacement and then some type of arthrodesis procedure. You know, these are both large procedures that carry high risk, especially in the setting of infection. There's some people that feel that revision replacements may carry a higher risk, although this isn't really proven in the literature. Arthrodesis in these cases are not as simple. The bone quality is not great. There's a large bony void. You need some type of structural allograft. So there's usually a high non-union risk with these cases, as we'll see. I'll usually counsel the patient on these two options and let them decide. For older patients or higher non-union risks, I lean to a revision replacement just because of the risks of a non-union. For revision ankle replacements, I prefer a stemmed implant, but having an implant that has good, robust distal tibial fixation will be important. Having revision polys or options for base plates, all kinds of sizes available, and really preparing to treat this much like a deformity ankle replacement case like we heard about earlier. Soft tissue management is crucial here. For all my revision cases, if I have any concerns, I involve plastic surgery. I have them available if I'm concerned about getting the wound closed well. I'll use incisional wound vacs for this, TXA to help prevent any kind of post-op hematomas. And infection prevention is key here. I'll use vancomycin powder intra-op and Cef-N-Vank and often send patients out on PO antibiotics. Again, there's not really any literature to support this, but infection prevention here is key and soft tissue management is crucial to that as well. So what are some of the outcomes? This is a study that was published about in the past year looking at revision ankle replacements for chronic infections. A sample size of 11 patients looked at a median three-year follow-up. It's important to note that seven of these patients had reoperations. I believe three of them were for infection. So for a recurrent infection, one went on to BKA. These are two other studies that looked at revision ankle arthroplasty in the setting of infection. Both of these are more of a heterogeneous patient populations, some one-stage, two-stage. The overall message from this is, you know, good outcomes in about 60% of patients. The highest rate of infection was with single-stage revision. These are just not straightforward cases. Any kind of revision arthroplasty in the setting of infection carries risks and it's important to counsel the patients accordingly if you're going down this road. So what about orthodesis? You know, ankle fusions in these cases usually isn't enough. The bone stock in the talus is pretty poor. So some type of TTC orthodesis is preferred with your construct of choice. For me, it's a hindfoot nail. You usually need some type of structural graft here for the large bony void, whether that's allograft in the form of femoral head or fibular strut or a custom or off-the-shelf cage. For bone grafting in these kinds of fusions, my philosophy is to just throw the kitchen sink at it. I'll use everything and anything I can to try to get this to heal. So allograft, autograft, augment, you know, whatever you can do to get this to heal and avoid a non-union is crucial. And again, surgical approach, like we've heard, really just depends on the incisions available and the patient's soft tissue envelope. So looking at structural grafts, you know, allografts, you know, they're lower cost. There's more data available for these, like femoral head, fibular strut. One of the concerns is their stability. Can they collapse over time? These just, for all of us that have done these cases, these are just hard to get them to fit in well. So they're not patient-specific and compression through these is sometimes tough. Now on the right here, cages, whether they're patient-specific or off the shelf, they can have good mechanical stability, but they can sometimes take time to print. They're higher cost. There's not as much data to support their use. And there's this question of whether more metal increases the risk of infection. Now, these are two studies that looked at TTC with femoral head allograft. It's important to note these both weren't just for ankle replacements or infected failed ankle replacements. The overall message here, again, if you look at this is that there's about a 50% fusion rate and a 16 to 19% amputation rate. So these are not straightforward fusions. They carry high risks, complications that can result in amputation. And it's important to counsel the patients accordingly for this and prepare for this as well. So coming back to our cases, you know, this first case, 65-year-old gentleman, otherwise healthy, kind of an acute infection, good host, good soft tissue envelope. Ultimately for him, we elected a one-stage revision with an IND and a poly exchange. We had plastic surgery intra-op to help assist with closure, particularly at the sinus tract that we had to excise and incisional wound vacuum closure. Deep cultures grew MSSA at six weeks of IV antibiotics, trended the ESR-CRP and ultimately the wound healed, patients ambulating well without pain in three months. And then looking at case two, this is kind of more of a chronic infection, large soft tissue wound with exposed to bandwidth drainage a couple of months out. Ultimately elected to go for a two-stage revision here, first with an IND, complete explant of all components and an antibiotic spacer here seen on the right. Plastic surgery at the time of the explant performed a free flap for him, six weeks of targeted antibiotics with ID consult, ESR-CRP normalized. Again, he had a six-week antibiotic holiday. We did try to re-aspirate him before we moved on, didn't really, it was a dry tap. Based on the ESR-CRP, we felt comfortable moving forward. As a younger patient, preoperatively, not a lot of motion, so ultimately elected to have a TTC. And so he underwent a TTC with a femoral head allograft about three months after the initial surgery. So in conclusion, more ankle replacements are being performed. So we will see more infections as more and more of these are being done. So it's important for us to know what to do when these come and how to manage them. But again, the diagnosis is really not well-defined. Most of what we use is based on hip and knee literature and the management is also pretty variable. There's a lot of options and there's not a lot of good high-powered studies to help guide us. Salvage is possible and preferred in most cases, but it does carry risks and you have to be careful as you plan these operations and also counsel the patients accordingly on the complications and risks. Thank you for the time. Thank you, Rishi. Next, we have Constantine, who's talking about a very complex subject. One that you saw me get in trouble with earlier in my incisions talk. Constantine is also from the hospital special surgery and also a Duke fellow. Take it away. Thank you very much. Hopefully you guys can see my screen and can hear me. So we'll talk about fusion takedown, if ands and buts. My disclosures are here and also listed on the mobile app. So ankle fusion has some pros. It provides pain relief. If you have good hind foot joints, then you can compensate for your loss of ankle motion and do pretty well for a period of time. And you can resume impact activities. So particularly if you're a laborer or have a high demand job or high demand life and are particularly young, you can resume those activities to a certain extent. But of course, with everything, there are some negatives. You lose motion at your ankle, develop adjacent joint arthritis. And as we discussed a little bit earlier, when you develop adjacent joint arthritis, those fusions have a high rate of non-union. So one thing that's also important to remember and we've all experienced is that not all ankle fusions heal. And the non-union rate has been reported as high as 10 to 12% in this study, but certainly at least 5% of the time ankle fusions don't heal. There's also an ideal position for your ankle fusion. And as I like to think of it, there's only one right spot and then all the other ones are wrong. And so you wanna get them in neutral position, slight external rotation, a little bit of valgus in the hind foot. And it's unclear what the incidence of malunion is, but in this study from 1980 in JBGS, they reported a 12% incidence of malunion. And so if you fuse the ankle in the wrong position, you're certainly gonna have a difficulty. The patients are gonna report pain, difficulty with ambulation, difficulty with activity. So malunion is a real issue. And as we all know, adjacent joint arthritis. So if you fuse the ankle, particularly if there's a malunion, but even when you fuse it and it's done just right, patients will develop adjacent joint arthritis, typically subtalar joint first, but also the talonevicular joint and even down into the midfoot. So then what are the indications to undo an ankle fusion? Well, the best indication is a non-union. So particularly a non-union in a patient who just recently had the ankle arthrodesis procedure. Malunion is also a good indication for a takedown. A relative indication, at least in my experience, is adjacent joint arthritis because it's unclear when the right time is to do that procedure. So you never really know when to pull the trigger and undo the ankle fusion. Do you need to fuse the other joint or not? So there's no good rules on that. And sometimes those results aren't so reliable. And certainly there's contraindications, absent malioli, poor bone quality, and other contraindications to generally to ankle replacement, like poorly controlled diabetes, neuropathy. And you guys have heard plenty about a poor soft tissue envelope. So what does our literature show? Well, there's not very much literature on this topic. Grysberg published the Seattle experience, 19 ankles with three-year follow-up. And there were a lot of complications. Half of them had intraoperative fracture. Five required revision, but 15 out of 18 were satisfied. Not very satisfied, but satisfied. Now Hinterman in 2009 published his experience, 29 ankles followed for about five years, 83% satisfied. But out of those 29 ankles, really only five were pain-free and 21 still had moderate pain. One had to be converted back to a fusion. Pellegrini, another Duke fellow, published the Duke experience in 2015, 23 patients with three-year follow-up and 87% survivorship. So more than 10% of these patients had failed in the first three years. 43% low-grade complications. So basically half your patients are gonna get some type of complication. Now this paper in 2022, this is Chris Cotilla's experience, 51 ankles at four-year follow-up. And really this is the best data I found on takedown of ankle fusion. Yes, he had some reoperations, one failure due to infection, but look at that range of motion. I mean, it's remarkable. And I'll say it's better than what my patients have experienced. So I think we have a lot to learn from how he does it. But this is really the best, the data that's out there for ankle fusion takedown. So I'll show you some cases of mine. I'll talk to you about some of the challenges in my experience. Here's a 43-year-old female one year after ankle arthrodesis with a non-union. So I'll say that this is almost the perfect patient to do it because they have a non-union, they're well-aligned, they have reasonable bone, they're young. And so you can perform an ankle replacement and use a pretty standard type of implant and even minimize the resection on the talus. Here's another case, similar case of a patient with a non-union relatively recent after the ankle arthrodesis procedure. And here you see another implant, a reasonably low profile, but one difference is you see a flat cut tailor component. And sometimes I think it's easier to do a flat cut tailor component when you're taking down an ankle arthrodesis or an ankle fusion, but it also provides you a wider surface area to oppose against the bone. And sometimes that is helpful, particularly as you can see in this case, the screws are kind of going into the same spot. So you know you're going to have to bone graft that void once you take the screws out. But you can see here that a non-union, a recent non-union, you can still achieve very good motion with your takedown. Here's another great reason to undo an ankle fusion. This is a malunion. So you can see here, this is somebody that autofused, 52-year-old female with rheumatoid arthritis, and they're fused in Aquinas. And so you're going to transfer all that weight into the talonevicular joint in the midfoot. So she presented with a talonevicular pain and an Aquinas malunion. So she had to take down using sort of this keel, the tibial component for better fixation, a flat cut tailor component to again, broaden that bone metal interface and get stability. And I performed a concomitant talonevicular arthrodesis to obviously address the pain generator and got the foot in a better position, maybe not perfect, but certainly better than what she started with. All right, now we're into the relative indications, right? So here's a 46-year-old male with hemophilia, nine years after ankle fusion. And the ankle is not fused in a bad position, truthfully. I mean, maybe a little bit of Aquinas, but really not a bad position. And as you can imagine, this patient has subtalar pain and he absolutely does not want a subtalar arthrodesis, just doesn't want it. So I performed a takedown. You can see here a stemmed implant. And you can see, I really did as best as I could to clean those gutters. I really wanted to get motion back for this patient. And you can see here intraoperatively that I'm able to achieve pretty good motion at the ankle. But as you can imagine, after the surgery, and once all that scar tissue sets in, you can see here in his dorsiflexion plantar flexion x-rays, I've lost a lot of that motion. He still has motion better than what he had before. And he still does not have his subtalar joint fused. So it's a win. But again, this falls under the moderately satisfied patient, not the completely pain-free patient. Here's another patient, 52-year-old female, seven years after ankle fusion. And you can see here, this patient presents with subtalar pain, subtalar arthritis. And again, this patient absolutely does not want a subtalar arthrodesis. And then I'm looking at the section and I'm thinking, well, does, does that thing count as a malleoli or not? I'm not so sure, you know, as it's the fibula, but it's not really where it's supposed to be. It's, it's been incorporated in the arthrodesis, but we'll try anyway. So here you see an implant, a longer stem. Again, this is a modular implant, so you can adjust the stem with the stem height based on the bone quality. And here you see a revision type tailor component that is even more broad to capture even more of that bone to resist subsidence. So if the bone is really soft, I can use this type of implant. And as Elizabeth mentioned in the beginning of this, you want to have all your options available. And so in this case, I use this bigger implant and you can see there a tiny little screw to protect the medial malleolus. And here she is post-op, but what happens, right? We talked about these things that they can get complications. So what happens, this patient has medial gutter impingement. And as many of you know, from your experience, medial, well, any gutter impingement, those patients can often be just as unhappy as when they had arthritis and she was that way. So I had to take her back and debris the gutter and you can see here, this is about the smallest medial malleolus I have in all of my ankles, but it held up, it held up. Of course, patients always blame the screw. They think the screw is the problem, so you have to take the screw out. You're kind of stuck to take the screw out, but thankfully the medial malleolus held up after the debridement and here she is happy with her takedown many years later. This is, I think, at least five years. Here's another patient, a 57-year-old male, 10 years after ankle arthrodesis, and he presents with tail and avicular joint pain. And you can see here, this ankle is fused in a perfect position and he presents with tail and avicular pain. So what do you do? Well, I did a takedown and I did the tail and avicular arthrodesis at the same time. And you'd think I'd learned my lesson. You'd think I had, I would pay better attention to the medial gutter, but I failed, I didn't do it. And so this patient presents with medial pain and you're thinking, well, is it the medial gutter or is it the tail and avicular joint? So here's a CT scan. This is actually a CT scan obtained with a simulate device that allows you to see a weight bearing image. And you can see here that I have medial gutter impingement and arthritis, but you can see here that my tail and avicular joint looks pretty healed. So I can focus on the gutter, leave the tail and avicular joint alone, take him back to the operating room and debride that gutter. And to be determined, we'll see how he does. This was a recent case. So here's another case, 51-year-old female, had an ankle fusion, but had limb deformity. So obviously, you know, we test these patients, we assess them top to bottom. So in her standing hip to ankle alignment view, you see here that there is a complex deformity of the limb. This patient was a polytrauma patient, big valgus deformity of the tibia. So we're going to stage this, right? We can't do all of this at once. So a colleague comes in and corrects the tibial deformity with a tibial nail. Then you can see here, the hip to ankle alignment is better. It's not perfect. It's better, but now we can at least address the ankle. So here you can see the tibial nails in place. We're going to undo the ankle arthrodesis and put again, a stem tibial component, almost ran out of room, but thankfully had just enough. And then you see here, I'm plating the medial malleolus, which I think is sometimes better than a screw. It depends on the bone quality and how thin the bone truly is. And here's that patient. She actually recently came back. She's six years out from this procedure. And even though it doesn't look great, you would think, boy, that ankle doesn't move. You could say, well, at least the foot's moving. It's moving more than it would have had the ankle been left as an arthrodesis. So she's been able to avoid also adjacent joint arthrodesis procedure. So that's a success. But they don't all work, right? And so here's a bad complication. A 58-year-old female had an ankle arthrodesis and presents with lateral hindfoot pain. And really her pain is in the calcaneo-cuboid joint. So I thought, well, I know how to do this. I'm going to undo the ankle fusion and I'm going to fuse the calcaneo-cuboid joint. And that's what I did. But you can see here, I got into a lot of trouble. The tibia is cemented. So you know, that was a problem. We typically don't want to cement them if we don't have to, but here it's cemented. And you can see that medial malleolus is really thin. Actually, it was fractured during the case. And as you can imagine, I did the calcaneo-cuboid arthrodesis, which was what was causing her pain. And here she is a year and a half out from the procedure. And the medial malleolus is a nonunion. And the tibia is loose. And the talus is slightly subsided. And she is miserable. And this is the hardest thing you have to do if you tackle these types of procedures, is you have to sometimes reverse it. And so here she is. I took the hardware out, took the medial malleolus out. And I was able to spare the subtalar joint, which was a win. It would have been a real shame to have to fuse a subtalar joint in her. So I really did everything I could. So here you can see a femoral head allograft fashioned to fit the defect, an anterior plate and a crossing screw. And here's a CT showing that, thankfully, it healed. And here's her final follow-up. So what are my tips? Well, one thing I've noticed in these cases is that the bone remodels. And really, the cortical rim is very dense. But the bone centrally is very soft. And there really is bone loss. And so what that means is that I now prefer stemmed or keeled tibial components more than a low-profile implant for the tibia. And I really emphasize anterior to posterior coverage. And I think of this both for the tibia and the talus. You really want to broaden the surface area between the bone and the metal to really try to get it to heal and prevent subsidence. As I showed you in the papers and in my experience, there's a high intraoperative complication rate. So protect the malleoli, screws, and or plates. And early range of motion to combat stiffness. Because even though you can achieve the motion during the surgery, many of these patients will lose it afterwards. Thank you. Thank you. That was fantastic. I've done a number of those. And each time I do it, I cross my fingers and kind of hope that I don't get in any trouble. We do have a couple of questions. The first is from Jeremy. He just wanted to get articles about surgical approaches and TARs. So Jeremy, you'll be able to pull up all of these talks. And in my particular talk, the references are there. So you can find those there. The next question is from Eric. And he wants to know, is there a cutoff for age for doing a TAR? So I'll throw that out to the panel. Is there a cutoff for age for doing a TAR? I can take it. I don't have a cutoff. I've done them in patients as young as like 30. I mean, my thinking on it is even though the classical teaching is that you're not supposed to do replacements on younger patients. When you're younger, that's when you want the good function. That's when you want the good quality of life. That's what I would want at that age. So I think as long as you have a really frank discussion with patients about it, these younger patients, they understand that they're going to need probably multiple revision procedures on their ankle. I think if they are a reasonable person and they can understand the risks and you can have that productive discussion with them, I think I don't have an age cutoff. So as long as I think it's the right patient, I don't have a cutoff. I assume that's what you meant, the younger age, not older age. Yes. Yeah. Errol, I want to just add to Elizabeth. I completely agree with her. There's no hard set number. And I think one thing I'd be mindful of is if you take a 41-year-old patient, take a 41-year-old patient who fractures their ankle when they're 20 and they have post-traumatic arthritis for a number of years. They slowly change their physical activity. They learn to live with it. And then they finally accept that they need to do something and have a surgery and they have an ankle replacement. That 41-year-old patient is different from the one that was perfectly normal up until they were 39. And then they have a really bad accident. They have AVN of the distal tibia. Maybe they had a malunion of their ankle fracture. Now they have terrible ankle arthritis two years later. And that person, that 41-year-old still remembers their 39-year-old version that was normal. And they expect very different things from their replacement than the other 41-year-old patient that's lived with arthritis for a long time. Now, I'm not saying that one should have one procedure, one should have another. But I'm saying is you have to really treat those patients differently and talk to them differently about the surgery. Because I have had the experience where they think their ankle is going to be normal. And we all know it's not. And so we just have to spend that extra time to counsel those patients. Yeah, I would agree with that. I don't have a specific cutoff more so than what the functional goals are. You know, in younger patients that are looking to do a lot of high-impact labor kind of work or what they're expecting to get out of this may not be as happy with the replacement. So age is just one part of the equation. I think it comes down to what their expectations are, what they want to do with the replacement. Elizabeth, anything to add there? Agree with everything that was said. I do have a question, Errol, for the panelists. Currently, there's a lot of, I guess, for us, you know, we're biased. We see a lot of total ankles out there. Obviously, the talus failure is a problem. I wonder if you all have any experience with the use of 3D printing and total talus in conjunction with total ankle replacement in your experience and the outcomes with it. You know, I think the question becomes, if you're able to preserve the TN joint or the subtalar joint, I try to do that in all cases. I think the challenge with the total talus is there's a lot of advancement in technology. And now you can 3D print these to have subtalar fusions. You can couple them with ankle replacements. But we haven't really figured out what's going to happen to the TN joint. And so that's a challenge is once you take out the whole talus and the TN joint fails, what do you do now? For total taluses with total ankles, there are revision cases where if there's bad talar subsidence in an older patient, that can be a good option for them to preserve motion and not have to undergo a large TTC fusion procedure. But I think you just have to be careful just because we don't know what's going to happen to the TN joint long term. And there's not a lot of data or literature out there on it. I agree with reserving the total talus in those kinds of situations for older patients. I mean, like I said, I don't really have hard stops, but I do feel also very nervous about doing something like that in somebody younger or higher activity. But for somebody older, I think it's a really good way to allow them to rehab a little bit faster and remove that risk of nonunion or failure that you get with like a bigger TTC fusion. And when I do, I do have a preference for incorporating a subtalar fusion. I just think it's going to make it more stable and more likely to succeed. I don't know that we have any good long term data on how straight up total talus, total ankle replacements do. But incorporating the subtalar fusion just makes me feel like it's more stable and overall more likely to work. Yeah, no, I agree. I think if you're going to just do a total talus in the trauma setting, it's fine to do that. If you're going to couple it with a total ankle, it's best to try to do an arthrodesis procedure to the calcaneus. The talon ovicular joint is a problem. And when I've had to deal with that, I've either shortened the neck of the implant. So almost leave a space between the implant and the navicular or can do an interpositional arthroplasty almost of the talon ovicular joint. But I think the biggest and I think we're all saying the same thing, which is it's the absolute only when it's absolutely necessary. I think there are instances that I've seen of patients that could have had a total ankle or a revision total ankle, did not need to have a total talus, but it was done and it's a real shame. So I think using the implants that we have currently to their maximum before taking away the entire bone. Excellent. Next question from Kevin is for Constantine. With fusion takedown, are you doing any extra steps to regain motion at the ankle? And if you get that motion, how do you balance wound healing with early range of motion? Yeah. So I didn't really go through the step-by-step procedure of it, partly because I don't have good photos of it, but the first thing you have to do is set your joint line, which isn't so easy sometimes. I showed you some of those cases where the fusion was a long time ago. It's a cylinder of bone. So you kind of have to sort that part out. But once you set your joint line and you make your cuts, you're basically creating a box and you're creating the malleoli and that first case I showed where you're basically creating the gutters. That's probably the most important thing to get motion. Once the bone is out, you can sort of elevate the posterior soft tissues away from the tibia and just do as many releases as you can. But in the beginning, you are limited because not only do you want the skin to heal, but you want the bone to heal to the metal. And so range of motion for me starts at two weeks, but it's active range of motion. And at four weeks, they start weight bearing and active assisted motion and they do knee bends and they go to physical therapy. And I haven't been able to really advance them much faster than that, particularly because these are complex ankles. For those that have been stiff, I have not gone back to do anything unless they have pain, which those patients typically have had gutter impingement. And then with a gutter debridement, you can basically move them a lot faster because at least the bone has healed to the implant. You're just worried about the incision. So that's how, yeah, so that's how I handle it. I have a question for the panelists. In all the cases shown, you guys have great, tremendously clean gutters. And I think for those who haven't done many, that's a great teaching point. If you all could share your secrets to gutter cleaning and because that's, as we all know, that's going to be one of the reasons these may fail five or six, seven years later. So I'd like each of you to address that if you could. Yeah, I can start. At the end of the case, once I get all my implants in, I'll go back through with the recip saw and I'll kind of go down right along the edges of the tailor implant and take as much bone as I safely can. I'm open to using a smaller size talus than I think I need and doing a more aggressive gutter debridement. So removing some of the medial lateral tailor bone and using a smaller talus than putting in a large talus I found has helped. Yeah, I try to do my debridement before the final implants are in. So usually I'll do it after like both cuts, both tibial and tailor cuts are done. And I use the sagittal saw running it down both the medial malus side. Sometimes I'll resect a little bit of the fibula and also on the talus. I try to avoid taking a lot of bone off the talus and so I take more off the medial provided I can. So I do think it's important to avoid oversizing the implants if you can, because then that can make getting clean gutters harder. The reason I try to do my gutter debridement before the implants are in is because I've had the experience of trying to do too much gutter debridement with the implants in and a patient with soft bone and it actually destabilized my tailor component. So I'm very careful about that now. Yeah, you know, the only thing I'll add is I use a small reciprocating saw. Some have used burrs, but I think it's something more than a ronger is necessary. And then I think to be mindful that everyone can be brave anteriorly, but it gets harder to do that posteriorly. And so a lot of times what you end up doing is you go to debridure gutters and you clean out the front, but then you forget about the back or so I'll do it in two steps. I'll clean out for the medial side. I'll clean out the anterior portion of the gutter and then I'll try to match the back to match what I cut in the front. And a lot of times I'll cut, let's say 85, 90% of it with a reciprocating saw and then finish that back corner with an osteotomes just so that I'm not putting the saw up against the tendons in the back. And to Liz's point, the fibula posterolaterally, I'll get that very early because that often will block your talus even from reducing in the right position. You can't even get your trial implants in place, particularly for ankles that are very externally rotated or the fibula sits posteriorly. You almost have to remove a little chunk of fibula to get the talus working properly. Yeah. And that little, the smallest straight osteotome, I think is a really useful tool for the gutters. Like, so usually like Constance said, I'll start it with the recip saw, but then using that little osteotome, it not only helps complete the cut, but it's also really useful to lever the pieces out once you have them cut. Okay. We have two more questions, then we'll move on to Glenn in the next section. This is from Erty. Erty, and this is for the panel, whoever wants to take this one. Does adjacent segment arthrodesis have high non-union rates after arthrodesis takedown? Does adjacent segment arthrodesis have high non-union rates after fusion takedown? Yeah. I don't know the answer to that scientifically. I don't know that if that's been looked at at a paper to compare. Chris Cotia's paper, there was one revision of the subtalar joint, subsequent procedure from that cohort of, you know, 50 some cases. I try to avoid, I think probably try to avoid doing the adjacent joint arthrodesis when you do the takedown because, you know, one of the themes that we mentioned is that doing too much can get you in trouble. So it's okay to do it in stages. Now, I showed you some cases where I did them at the same time. I will, I think doing the talonevicular joint at the same time as a takedown or at the same time as an ankle is a lot easier than the subtalar joint and also protects the ankle a little bit better. I think the ankle and the subtalar joint work a lot more hand in hand than the ankle and the talonevicular joint in terms of motion. So I don't know if it's a higher non-union rate, but you also have a lot of bone available. When you take down your ankle arthrodesis, there's plenty of bone to bone graft. So it seems like a good way to use it is to put it in the joint that you're trying to fuse. But I have not done subtalar arthrodesis at the same time. I try to leave that joint alone. Great. Final question from Jocene. Does extensive gutter cleaning increase the load on the poly as some think that the malleoli actually are weight-bearing parts of the ankle? Anyone? I sort of feel like if you're weight-bearing on the malleoli, you're going to have a problem with gutter impingement. So yeah, I feel like you can't hit both.

total ankle arthroplasty

complex cases

preparation

deformity

bone loss

surgical techniques

implant positioning

wound management

complication prevention

fusion takedown procedures

cleaning the gutters

rehabilitation

gutter cleaning