On behalf of AOFAS, I'd like to welcome you to the AOFAS Advanced Foot and Ankle Virtual Course, Revisions, Complications, and Complex Cases. Thank you to our course chair, Dr. Christopher Miller, and course co-chairs, Dr. Jacob Zeid and Dr. Elizabeth Cody, for putting together a fantastic course. You can find their disclosures, as well as the disclosures of the faculty, on the course webpage on AOFAS's website. All faculty will also share their disclosures in their individual presentations. I'd like to run through a few housekeeping items before we kick off the course. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. This course offers 11.75 hours of AMA TRA Category 1 credits. You'll receive an email following the conclusion of the course today, with a link to claim your CME. This course is being recorded. The recorded presentations will be available on the Demand Education Center approximately 24 hours from the broadcast. We encourage you to ask questions during the presentation. To send your question to the faculty, please click on the Q&A tab on the bottom of your navigation bar. We also want to give a special thanks to MedlineUnite Foot & Ankle for supporting the symposium Managing Complications of Forefoot Surgery with an educational grant. Funding for this course is also provided by the Orthopedic Foot & Ankle Foundation. To support education programs like this, please donate to the foundation on our website or by texting GIVEAOFAS to 41444. Finally, we hope to see you at our future education events, including next week's Foot & Ankle Focus webinar on 3D Printing of Foot & Ankle Surgery, and of course our 2025 Winter Meeting in Lake Louise, Canada. Thank you for taking the time to attend this course. I will now turn the program over to Dr. Miller. Thanks so much, Julie. Welcome. This is the third and last day of the advanced course, virtual advanced course this year. For people who are just coming in for the first time now, we've had some really amazing talks the last two nights, and those will all be available online. I hope you have a chance to check them out. Today, I'm really excited as well. We have some people coming from outside of the society and outside of the country who are joining and sharing their wisdom with us today, and I'd just like to say a special thank you to Dr. Christina Stukenborg-Colesman, who will be starting off, but she joins us from Germany, and really looking forward to her talk and everybody else's as well. I'll turn it over to Dr. Zeid, who's moderating the first section. Thanks, Chris. Okay, we're going to get started and jump right into it. This is going to be part two of the Malunions and Malalignment Symposium. We had a really good one last night for part one. Dr. Stukenborg-Colesman is coming to us from Germany. She is our EFAS representative this year for the meeting, and she's going to talk to us about complications of Lapidus. Take it away. Thank you very much for the invitation. It's an honor, dear chairs, dear colleagues. I was asked to talk about Lapidus complications. In Germany, probably you are known for this, that we do a lot of Lapidus procedures, or as I would say, TMT1 fusions. I will get to this a little bit later. Here are my disclosures. There is nothing to disclose for this talk specifically. So when we're talking about Lapidus, what we probably do very frequently, we are talking about the classic Lapidus arthrodesis, which means we're taking a section, shortening, and by compensating with plantar flexion for the shortening, we try to do this and fix this in terms of intercuneiform or intermetatarsal screw fixation. So this is known as a classic Lapidus procedure. But also we know if we really read the papers of Lapidus very closely, and this is already in 1931 between and 1959, he already said in doing this time that probably we do not need to resect a wedge, and also we probably don't need always to do an intercuneiform or intermetatarsal fixation. So we will see later on, I try this. So the TMT1, let me probably, you know, not taking the classic Lapidus procedure, but talking about a TMT1 fusion. It's a very successful technique, which over 90% satisfying results. So the technique over the years has evolved with stable osteosynthesis, no wedge resection, no mass shortening, no plantarization, and of course, a supination for reduction. The TMT1 fusion is a 3D correction. And if we're not talking about malunion, of course, this can occur in every dimension. So it can be adduction, adduction, dorsiflexion, plantar flexion, shortening, lengthening, probably not, but supination and pronation. So we have to address all of these things to avoid malunion or malalignment. I think the most common reasons for malunion or malalignment is probably the insufficient reduction initially. So because we all know, do it right the first time is always the best thing, but we try our best and it's not always sometimes evolving this way. So maybe also primary or secondary intercuneiform instability, insufficient correction of pronation, insufficient DMM correction, shortening, as I already said, MT1, or an undiagnosed foot deformities. So if we're talking about hindfoot valgus, metatarsus adductus, we have to address probably with our lapidus or TMT1 fusion too. If we look at this 20-year-old male, if we look at the intermetatarsal angle, the DMMA, the shortening, and the hindfoot valgus, so the question is, you know, what could have been done better? And probably we haven't addressed this correctly, or the colleague is that now not correction of the intermetatarsal angle, the DMMA, it's a little bit shortened and, you know, should we also address the hindfoot in order to not to have the recurrence maybe. So what did we do in terms of, you know, revision surgery? Of course, the hardware removal, lengthening, we take always, or most of the times, an autograft, an iliac crest, we interposition into the TMT1 for the fusion, and then we do some kind of osteosynthesis, either with a screw, in this case, it was also only a screw, but most of the times we do screw and plate. And of course, then we have to correct the DMMA also in order, we do this here with a distal osteotomy in order to correct this. So this is the final result, and we also add, because of the hindfoot valgus, calcaneus sliding osteotomy, we had wound healing problems, we had at the end a CRPS. So I mean, this is now straight or corrected, but of course still is probably pretty unsatisfying for the patient. Looking at another patient, 24-year-old, 11 previous operation, MRSI infection, and many other complications, and you can see here what we have to address here. So they tried to correct the TMT1, it's not fully corrected, the intermetatarsal angle, you can see the aching osteotomy in addition. And then they did a revision, and they tried to correct this, but still, you know, you can see the sesamoids still are not repositioned, they tried to take out some of the metal in the phalanges, as you can see, but it's still not satisfying corrected. So what we did in this position, I just have to make, one second here, smaller, sorry, now I lost it, one second, let's see, one second. Somehow, I don't see my presentation, unfortunately, so I will continue. I only see you, which is nice, but... One second, sorry. Here we go. And you can see here, we fixed this with an also iliac crest again to stabilize it, but we also did a really stabilizing osteosynthesis with multiple plates, also fusing the intercuneiform joints to have more stabilization and to address this instability at the intercuneiform joint. Oh, let's see, what's this old here? Well, this is another 53-year-old female. As you can see here, this is what we addressed here in the first time, and we did like a classic lapidus arthrodesis. We did an intercuneiform or intermetatarsal screw fixation. This plate allows you to do this intermetatarsal screw fixation through the plate. And the question is, of course, when do we have to do it in order and what complication may we buy with this when we do this intermetatarsal fixation? As you can see here, the hallux is corrected, but after three months, the patient complained about pain under the third metatarsal and also under the first metatarsal. And if you look at this, you have a subluxation dorsally or dorsiflexion of the metatarsal too in comparison to the other metatarsal. And we did a CT, and you can see here, it's not the screw kind of pushed up the metatarsal. And of course, this is a complication and puts more pressure to the first and the third metatarsal head. What we did, we took the screw out and everything was solved. But of course, that means, you know, we have a powerful tool here and we really have to address this very carefully. Another 46-year-old female here. As you can see here, how powerful this correction is. And we have a hallux varus by the end, like an over-correction. And this is what we also always say is, we should just stabilize the inner cuneiform joint and not, you know, use this tool as an additional correction for our lapidos or TMT1 fusion. So here you can see you have loosening, and probably this is not the best screw. It should be maybe full threaded if you do this kind of fixation, as you can see here. We took out the screw and everything was nice, but of course this has to be really carefully addressed too. So in terms of the metatarsal screw fixation and to avoid complications, I would say it's a very powerful tool. You have to be aware of that. Over-correction, you can reach with inter-metatarsal screw. We have a melt position of the screw. You can have loosening or breakage. Sometimes you have to remove it if it's loosened or partially loosened. And of course it reduces the vertical mobility and gives the patient some stiffness. So in our hands, therefore it's only screw fixation if necessary. But how do I find out if it's necessary or not? So there is here the hook test, and you can see here from the pre to post-operative. Interoperatively, we do the steps. We fix the TMT1. We don't do any retrosection or plantarization. We try to have it neutral. Then we do the hook test. And if you still can mobilize the metatarsal one medially, and you can see the intercuneiform instability here, as you can see here, then we add the plate, and then we add an intermetatarsal screw, or even a little bit different, as I will tell you shortly. So as another patient, previous operation, two operations, as you can see here, and you can see here this intercuneiform instability. So even if you put a screw in there, having taken the test, you have to fix it so it doesn't get breakage or loosening of the screw. So we did a revision, as you can see here, with two screws, which was not a very big revision, took the metal out and did this. As you can see here, there is an intercuneiform instability. It's very mobile. Putting the two screws in, you have a fixation of your intercuneiform joints. So in order to address this intercuneiform instability, I think you have to do an interoperative testing in primary and revision to see if you have to address this. You should prepare the intercuneiform joint. I think this is often not done. So you have loosening, and then you have to do revisions. Then you can do an intercuneiform or intermittent tassel screw. And then the question is, should you do partial or full threaded screws? In our opinion, or in my opinion, intercuneiform screw, either partial or fully threaded, gives you less complications and malunions, as you can see here. So this is the beginning on the left side, and you can see this partially threaded intermittent tassel. Often I see loosening with this. So you can do like this intercuneiform screw. I think this has less complications. I do it full threaded, but I don't know any biomechanical data. You probably can also do it partially threaded. Two more complications here, a 56-year-old. You can see here, Alux valgus pes adductus. Three months later, pain under the sesamoid. You can see here, like, and that should be also intraoperatively in your first, you know, operation, as you can see here, shortening. You can see here the step. So you can see here the plantar flexion of the metatarsal one. Of course, that has to be addressed. And how can we address this? We took the metal out and did a dorsiflexion osteotomy, as you can see here. But of course, it would be nice just to avoid this in your primary by paying attention to the length and of course, to the subtle view of your X-ray intraoperatively. Is it important, maybe, if the patient tolerates it? I think, yes, it is. If you look here, 25 years after lapidus or TMT1 fusion, you can see this osteoarthritis in the navicular cuneiform joint. And of course, then you have to address this somehow, maybe 25 years later, which is also not as easy as we sometimes think. In the other direction, of course, you can have also a dorsiflexion. And if you can see here, this case, of course, is it's not a revision. We suggested a revision here by doing a re-TMT1 arthrodesis to plantarizes. I think this is too extreme just to do a plantar flexion osteotomy, probably. So I would suggest to, you know, like take the metal out and do a re-TMT1 arthrodesis by plantarizing the first ray. Yeah, another little bit more mild one, you can see here, this is like 6.3 millimeters. But of course, this gives you limited dorsal extension. And I probably here, if you only have mild dorsiflexion, then probably you can do like, or get away with a chialectomy. And sometimes, of course, also you have to do a plantar flexion osteotomy. Addressing a little bit the Hindsfoot, I said underdiagnosed in terms of complications, you can see this patient here, Halox valgus and Hindsfoot valgus. If you look at the literature, I think it's a little bit unclear. You know, on the upper side, you can see there is a correlation. On the other side, there is no correlation. So I think this, you know, stays to now a little bit unclear. So in my hands, I do, if it's symptomatic and I have a severe Hindsfoot valgus, I do an additional medializing calcaneal osteotomy just to be safe on this side. As you can see here, this is lapidus arthrodesis with minimal invasive medializing calcaneal osteotomy. So in summary, of course, it's always the best to avoid this complication. How can we do this in primary or revision? Joint preparation, I think today, only cartilage removal, no wedges. Correct the rotation, intraoperative hook test to see intercuneiform instability, and then do a selected intercuneiform screw. As I said, we do an intercuneiform and not an intermittent tassel screw anymore. In terms of severe Hindsfoot valgus, you can do additional medializing calcaneal osteotomy. In case of revision, CMT1 arthrodesis, I think it's really important to address and restore the intermittent tassel angle, the DMMA, the rotation, and the length. We do it by interposition and autograft with the iliac crest. And of course, it's a stable fixation. I think this should always, or in most cases, be a screw and plate to have really a stable fixation in your revisions. Thank you very much for your attention. That was wonderful. Thank you so much. Okay, now we're gonna flip the order just a little bit. We're gonna have Dr. Humberd go next from Penn, and she's gonna talk to us about failed flatfoot. Thanks, Casey. Good morning, everyone. These are my disclosures, the typical ones, the coffee worth of royalties that I get from Oxford University Press. I also wanna disclose that I had help. We all have help. So thanks to Cliff Jang and Liz Cody for giving me some cases. So here's a scenario where we're living the dream. This is a patient who came to me saying her flat foot felt like a suction cup on the floor. She couldn't stand her bunion. She dialed back her activities, and she wanted something, anything done. And I did this surgery for her. And then three years later, she comes to visit me at Penn. These are pre and post x-rays, and she tells me that she's training for the Marine Corps Marathon, and she'll send me photos of her across the finish line. So what happens when we're living the nightmare? So to try and address how to think through this, I thought first we have to understand where things went wrong when we get these referrals or when it's our own patients, and then thinking through our revision approaches. So I wanna make clear that we're talking about stuff very separate from non-unions, infections, tendon ruptures. We're talking about like the surgery itself healed, but it didn't lead to the result we wanted. And I think there's a few ways that you can kind of think through your surgical failure. Is it a failure distal to the correction where you still have supination or valgus? Is there plantar gapping at the first TMT and medial column instability that wasn't appreciated preoperatively? Has someone developed adjacent joint disease and now they have stiffness and arthritis? Or do they just get stiff, perhaps excessive lateral column lengthening, and now their foot doesn't have the mobility they need? And then under-correction and over-correction, which are pretty good broad categories. To try and go through this, I stole these slides from the University of Washington MSK website, which is something I give as a reference to all of my residents. But we gotta know where we're shooting for. You know, what's the plantigrade foot position? So I'm not gonna go in detail through these. I'm sure everybody remembers, but sometimes a refresher is always helpful, at least for me. So you're looking at your Mary's angle. If it's down, you have pes planus. If it's too high up, you have cavus. Similarly, we're looking at a tail-of-first metatarsal angle on the AP. And when you're abducted, your talus is pointing medial to the first metatarsal. If you're AD-ducted, you're going lateral. I love these lines, because when you're getting fluoro, my brain just kind of quickly registers them. If they're disrupted, the sima line, you kind of recognize that picture on the right. This is an architectural term for two concavities meeting. It's something that our brains really like. You know, you see this in a lot of architecture and on columns, and for whatever reason, our brains like these concavity-convexities meeting in a smooth line. And so when they're broken, you kind of recognize that something doesn't look right before your brain fully registers why. And you have it on both the AP and the lateral. And then, of course, calcaneal pitch. This is one that I find somewhat difficult to evaluate intraoperatively, because they're not really load-bearing. So you'll have the situation where you think that you got it right, and you didn't quite get it right. I try and do simulated weight-bearing using different devices in the operating room. But ultimately, this is why weight-bearing x-rays are so important, because you have lots of folks with normal pitch when they're non-weight-bearing and completely flat when they put weight on it. So going sequentially, when we're looking at why we had a failed flat foot surgery, and this is accompanying both when people have had joint sparing as well as arthrodesis, I think it's helpful to work from the back to the front. So do you still have residual subtalar varus or valgus malalignment? And getting this hindfoot heel alignment view is so helpful to try and figure out what's going on. And you can see kind of the relative shortening just by that heel being kicked out and someone who is incompletely corrected in valgus. You can also appreciate when someone still has increased planus or if they have persistent cavus. So now kind of moving more into the middle of the foot. Looking at our transverse tarsal joints, this is someone who'd had a fusion, and you can see that they were left with the foot abducted. And so that's going to be something that demands correction. And then this is a case that I took from Aneesha's foot and ankle clinics talking about some of these themes. You can see on the first x-ray, you have medial column instability denoted by plantar gapping at the first TMT. And so you can see initially the x-rays are looking pretty darn good. And then everything kind of shifts down and there was ligamentous stability. And you can also see on the AP ankle, probably the bigger problem there is that there's some deltoid instability. And you see that ankle just continuing to tilt out and out. This is not uncommon after triples. There is a paper by Dr. Baumhauer and others talking about the rate of ankle valgus after triple and where it's essentially that it was a stage four flat foot the whole time and it wasn't recognized. This is a problem that I feel like probably sees me more than I see it, where I missed the subtle instability that's happening through the naviculokineiform joint. We get so used to seeing recurrent This is also taken from Aneesha Kadakia's foot and ankle clinics. And in picture A, you see them initially. And if you really draw out those lines, you can see the deformity is actually at the NC joint. It's not going just pure through the post tip, but there is NC component. And initially the foot looks pretty good. And then you can see that recurrence. And for me, the picture between B and C where my brain automatically gravitates as you look at that angle of the staple, see how in one is kind of in plane with the foot and then it's cocking backwards because there's been persistent subluxation. This is obviously an incredibly supinated foot. And so you have to look for forefoot. Are you still stuck in supination or pronation? Did you over-correct? Did you under-correct? Was there stiffness that wasn't appreciated and addressed intraoperatively? And then of course, can always get arthritis afterwards and having to extend fusions or revise a fusion. This is a case in a foot and ankle clinic showing someone who had had a prior flat foot surgery and kind of everything fell apart with arthritis of the hind foot, arthritis of the mid foot requiring a large revision reconstruction with fusion. So for my brain, obviously if you have helix valgus, you got to address that. But because we had the Lapidus talk, I knew that that would be handled better by others. So when we're thinking about revision approaches for flat foot reconstruction and for including osteotomies and fusions, I think it's really helpful to think mostly through your hind foot and mid foot and trying to establish varus valgus, cavus planus, abduction, adduction. And obviously these have kind of typical patterns of going together. So when you have this hind foot valgus, we're gonna be starting to talk about calcaneal osteotomies. You can cut them and you can move them plantar, medial, lateral. So when we have a varus malunion, we have two options. We can do a lateralizing calcaneal osteotomy to try and shift us back over. Or we can do a Dwyer-type osteotomy when you do a lateral wedge to shift it over. And then many of us also like to add on a little bit of a cheat and do the lateralizing osteotomy. I went for the simple osteotomies here for the straight cuts. There are lots of people who are doing Z-types. Those are excellent options as well. But I'm just talking through kind of the straight osteotomies for right now. You have a valgus malunion. You can be doing a medializing calcaneal osteotomy. And with these, when I'm able, I generally am trying to add on some plantar translation. In terms of technical tip, making sure that you're bending the knee when you're doing this and you put your Steinmann pin in. One of the things I like to do, and I work with residents, is that when we do the cut, I will then put a distractor in, a flat laminar spreader, and then put my freer inside the osteotomy and tell the resident to try and hit the tip of my freer with the K-wire. And that's not only giving them good proprioception practice and targeting practice, but it's also giving time for those soft tissues to stretch. And then, after they've missed a few times, but we have something that's reasonable, I'll then take out the distractor and then flex the knee, try and really get the Achilles to stop being a deforming force, pulling that heel away from you. And then I'll do the shift, holding onto that wire and holding onto a wet lap. That was taught to me by one of my pediatric deformity colleagues so that I can kind of hold the position and then have them fire it in. And I found that I can really improve the amount of both shift medially, as well as plantarly for a really severe flat foot when I'm doing these osteotomies. Interestingly, this is a paper by Matt Conti and the team at HSS, and it was looking at where is the best position to put folks who've had a flat foot reconstruction. And this is an interesting argument that it may be better to overcorrect them a whisper in terms of where folks were happiest. So the folks who had moderate varus and valgus were less happy than the folks with just this mild varus. After kind of reading and reviewing this, I wonder if I've been slightly under-correcting some of my pes planus feet and that I should be a little more aggressive with trying to get them into neutral as opposed to something around five degrees of hindfoot valgus, which is what I was always taught. When you look at midfoot deformities, you're talking about both the duction and AD duction, plantar gapping of the first, NC subluxation, and adjacent joint disease. So when you have things like the AB or AD duction, what's really powerful are these transverse tarsal osteotomies. You can go straight across, you can do wedges. I think planning them out beforehand, especially with computer software, can be really, really useful. And no matter how many times I plan, it always ends up slightly different in the operating room. When someone is AB ducted, a medial closing wedge, sometimes you can take out this bone and then flip it around to the lateral side. So you're using your own autograft if they've had like a solid triple in the middle. And these biplanar deformity, I'm sorry, biplanar osteotomies are really powerful for pes planus correction as well as pes cavus. When someone is AD ducted, you're obviously doing the opposite and you can also shove the graft in medially to crank them open medially. This was a study from, I can't believe, 25 years ago or over 25 years ago, that was done by Steve Haddad. And it was looking at revision surgery for triples and obviously different than how we publish stuff today is because they're using AOFA scores, but they found pretty darn good results of doing osteotomies through fusions to correct deformity and realign the foot. This is another paper by Tulin, 21 years ago, and looking at how to do these transfers to tarsal osteotomies. The pictures on these are really nice. There's also in foot and ankle clinics a lot of nice diagrams and pictures that are worth if you wanna do a deeper dive in this area. Beyond the X-ray, beyond looking at it, things that patients tell you that you wanna be listening to, if they're undercorrected, they're gonna talk about medial foot pain. They're gonna say that they're still getting calluses on the medial foot, that they feel pronated. And you'll see that the foot's abducted, or the opposite. If you've overcorrected lateral foot pain, they're gonna have a supination deformity. They're going to be rubbing. They can get lateral stress fractures. So I tried to put together some guidance for a systematic approach of how to think for these. So if you're like me and you need to process not while someone's talking at you, these are where you want to do your screenshots. So this is someone with an under-corrected deformity. And this is how you can think through correction of the deformity. I stole this from Ken Hunt paper and foot and ankle clinics in 2017. And so if they're in hindfoot valgus, there are certain indications as well as contraindications. Always be thinking if it's flexible, you can do osteotomies. You can correct it. If it's stiff, you've got to fuse it. And so getting the heel back over into position, you can also do a medializing calcaneal osteotomy plus the arthrodesis if you have a severe deformity to address the midfoot abduction. If they're flexible, you can do these lateral column lengthenings or do it through the CC with a fusion if they're less flexible and have some arthritis. And then the transverse tarsal osteotomies, which as I just discussed before, is super powerful. And then addressing the forefoot, obviously a lapidus can be really powerful if you have a combined deformity with a hallux valgus. And as well as if you're just pure supination, you can pull it down with the cotton osteotomy. What about when you have the opposite, when you have an overcorrection of a deformity? So this is my stealing from Ken Hunt and his partner from the foot and ankle clinics. And this is my version of that graph. So this is your second screenshot for a quick reference for later. So when you have the hindfoot varus, again, you're thinking, are they flexible or are they stiff? Do you gonna lateralize if you have still some motion or you can add on the Dwyer with a subtalar arthrodesis, you can add on a lateralizing calcaneal osteotomy with the arthrodesis. You're looking at the midfoot, you again can be doing these transverse tarsal osteotomies. And if they are flexible, you can be shortening through the lateral column. And then with forefoot pronation, this is very similar to how you just start to think through these CMT patients. So how do you get yourself over? Finally, and I love that my prior speaker here emphasized this as well. It is always easier if you want eggs over easy to get them right the first time. Once they come to you scrambled, I always tell my patients, listen, this egg is scrambled. Eggs over easy is now off the table. We're gonna have to try and figure out a frittata together. So watch how you scramble these eggs. Also think about things such as muscle balancing. I really love Brevis to Longus tendon transfers. If somebody has that flexible first opposite, obviously when we're thinking through a CMT type patients, make sure you get that Achilles in the right position. And don't forget the deltoid. Don't forget the spring ligament. If they are unstable ligamentously already, and it's something that you're not able to correct in the operating room, I recommend having a pretty low threshold for adding on a fusion, particularly of that first CMT or NC. If that's where the deformity is, go where the money is, right? You might wanna overcorrect that High Foot Valgus just a little bit, get them to zero to five based on that paper from Conti. And just as a tip in terms of how I like to do these really severe deformities when I'm doing a triple, I generally like to fix the TN first provisionally with a K wire to make sure that I can reduce their AB duction. Because once you've locked in the hind foot in terms of the sub-tailor joint, you're gonna really struggle to swing that foot over if you haven't already fixed it. So I'll often pin the TN, not just provisionally. And then I will make sure I can get the heel over and then I'll go back and finish the TN. But every now and then you'll think that you have it. And in fact, you still have malalignment through the sub-tailor joint. And it's really much more frustrating to try and go backwards and have to pull out those sub-tailor joint screws. I have some cases, but I fear I'm over my time. So I'm gonna pause here and let Dr. Brodsky take over. And then I have the cases available after if helpful. Awesome. Thank you so much, Casey. That was great. Now I am going to turn it over to my esteemed partner, Dr. Jim Brodsky from Dallas, who's going to be talking to us about revision peroneal and ankle ligament reconstruction. Hey, hello, everybody. Let's see. This is where we work. My disclosures are royalties from a Smith and nephew. And my other disclosure is that on the inside, I feel tall. And I haven't really emphasized that in the past. This is a 70 year old lady who has the most common type of peroneal tendon tear, which is a split tear of the brevis. And while it's clearly in about two halves, what's important is to see that each part of each half is also shredded. So the tendon is not really viable. And it shows a key role of subluxation and tears of the peroneus brevis tendon. Here's another 36 year old lady. We're in the midst of this correction, but you see that not only is the tendon been split into parts here and here, but the nature and chronicity of the tear is the obliteration of the normal color and pattern of the fibrils and the replacement with this very white looking scar material. And this is what it looks like here. This is the distal tenodesis after excision of the damaged section of the brevis. And this is the proximal portion of the tenodesis to the peroneus longus before the middle segment, which is split, is excised. This is a 63 year old rancher with a version of the same. You see that the tendon is completely obliterated in terms of its normal texture and color. It's folded into a C shape, matching its subluxation chronically against the posterolateral edge of the fibula. It's always important to pick up the edges of the tendon to really understand how badly damaged it is and to look at the undersurface of the tendon in particular. Diagnostically, it's essential in our practice to have imaging that looks at the peroneal tendons with a parasagittal or paraxial oblique that is pretty much perpendicular to the posterior facet of the subtalar joint to the peroneal tendons. So as we trace this particular man's MRI down, you see here that we're catching the C shape of the peroneus brevis where my pointer is. And here's the peroneus longus. And then as we move distally, you see an enormous amount of cyanobitis around it. There is gray inside of this particular cut of the brevis where it's in two different pieces. Here you see that even in lower, where it's corresponding to this red section that it's beginning to reconstitute into a single mass, there's an enormous amount of signal inside the tendon. And here you see, again, there's white, there's gray, and there's very little normal signal in the tendon. Left here is the peroneus longus beginning to go into the cuboid tunnel. Now, tenodesis is very functional. And this is a patient who's seven years after tenodesis of a split peroneus brevis transferred to the peroneus longus. She also had an osteotomy of the first metatarsal. And, all right, now try. And this is her aversion strength. Seen in one direction. And from laterally. You can see the tenodesis beneath the skin here and here. Now, let's talk about some cases. This is a 19-year-old female track athlete with two years of lateral ankle pain, but no instability that was not diagnosed correctly as being a peroneal tendon tear. Her heel is here, her toe is here. And this is what the tendons look like when the sheath is first opened. Doesn't look that bad. But when you look more closely at the brevis, you see that same C-shape cross-section of the peroneus brevis. We know it's the brevis because of the muscle being more distal. And it's probably a low-lying brevis muscle belly, which contributes to crowding inside the retinaculum. But when we take the same patient and hold the edges of the tendon, we see that she has a very significant split tear with damage of the brevis. So the issue is, do we repair it or do we excise it and do a tenodesis? In this case, because she was 19, I did a repair. Now, repairs of the tendon, to me, are when there's a segment of tendon that remains, or at least looks to remain viable. But to repair the entirety of a tendon will never be successful. This is based upon the first article John Kraus and I published about 25 or more years ago. But the problem with repair is it doesn't always work, even when it's done with strict indications. This is a 16-year-old volleyball player who had to quit one year after a brevis repair. And this is the source of her persistent pain. Here's the brevis that's been repaired. It doesn't have the normal color and consistency of the longest, but it seems to have healed reasonably. But it's entirely scarred down to the sheath as a result of the repair. And the immobile brevis tendon is painful when she attempts to contract her peroneal musculature. So in this case, and there's a small recurrent tear, there's no choice but to excise it and do a tenodesis. On the other hand, here's a 15-year-old baseball player. And he has a smaller tear, right, with more of the tendon remaining that looks to be viable. But what's really clear is in this boy, the tendon, the peroneus brevis is subluxing in the peroneal sheath. And you can see in this position how the brevis is pulled against the edge of the fibula. Now, in this case, the goal is not just to deal with the tendon tear itself, but with his instability of the tendons. And in this case, because the superior peroneal retinaculum was very attenuated, I did a split Z reconstruction of the calcaneofibular ligament over the peroneal tendons because no other method medializes the tendons more than this. And it has the advantage of not causing the tendons to stick to the underlying fibula as it would with a groove deepening. Now, here is a 20-year-old college basketball player who has not only a chronic split tear, but chronic tearing and really obliteration of the size, the color, and the texture of his brevis. It's really not a viable tendon. And in his case, the subluxation is extreme. The tendon has sublux within the peroneal retinaculum. The sheath is elevated off the lateral surface of the fibula. And in this case, it needs a more extensive reconstruction. Here, the posterior leaflet of the superior retinaculum is sutured into a roughened edge of the fibular margin and tied through drill tunnels, following which the anterior leaflet is brought over it to reinforce the reconstruction. So, very quickly, we've talked about the role of subluxation in peroneal brevis tears. And brevis tears constitute about 70 to 75% of all peroneal tendon tears. Now, I want to talk about the role of a number of other issues. Cavoveris, what's to do about tears of both tendons? And if we have a few minutes left, is there a reason to repair peroneal tendons in the presence of hindfoot fusion? This is a patient who's 47 with CMT. She has an asymmetric cavoveris on the left side, of course. And this is what her split tear of the brevis looks like. Veris is associated with brevis tears. Now, in the evaluation of cavoveris, you see this patient has a bilateral cavoveris. There's no question that when the patient is standing viewed from behind, that the heel is in veris. But when the patient is placed non-standing, either sitting, or in this case, and this is the easiest way to do it, prone, you see that the heels clearly come into a valgus position. This is the Coleman block test made easy. No blocks. It's just the comparison between heel position, standing, and not standing. If the deformity is correctable non-standing, then the hindfoot is flexible, and the veris has to be forefoot driven. So, while one can choose to do a calcaneal osteotomy for this type of veris, to augment the static deformity, the osteus deformity around peroneal, peroneus brevis tears, theoretically, the most important, not theoretically, practically, the most important thing is to correct the forefoot pronation, the plantar flexion of the first ray. And this is because in veris, the vectors biomechanically work to pull the peroneus brevis forward against the fibula. Eversion, and reciprocally inversion, is multiplanar. So, eversion is external rotation, dorsiflexion, and pronation, but inversion is the opposite. It's internal rotation, plantar flexion, and supination of the hindfoot. The veris stretches the tendons against the fibula, even at rest, and it pulls the brevis forward and laterally. At the same time, the longus is behind it and compresses the brevis against the fibula. These are the axes of the ankle and of the subtalar joint, as you see from these dotted lines. Anything that's medial to the dotted line in the right-hand side is an inverter, and anything that's lateral to the axis of the subtalar joint is an everter. The same is true in plantar flexion, dorsiflexion, relative to the axis of the ankle on the left side. So, what this tells us is that the peroneal tendons are plantar flexors because they're posterior to the ankle axis, and the Achilles tendon is an inverter. And there's more to say another time. This paper done by Kira Taniguchi with me on cable veris association with brevis tears, looked at surgically proven tears with age and gender match controls, a level three cohort study. We had 73% brevis, 8% longus, and 19% tears of both tendons. And radiographically, we proved with the controls that measures of veris are statistically significantly associated with peroneal tendon tears as a group. And then we broke them down into the surgically proven subtypes. We showed that calcaneal pitch and talofirst metatarsal angle and talovicular coverage angles were all associated with abnormalities radiographically proven cable veris. Now, the next thing is to talk about the surgical dilemmas of how to deal with tears of the brevis and the longus concomitantly. It's the least common category besides isolated longus tears, but the most severe and the most difficult. In my practice, they are frequently, if not always, but frequently, usually previously operated. And the word tear does not adequately describe the pathology here, because it's really not just a tear, but a destruction of the peroneal tendons. This is the type of patient I'm talking about where there's been a repair done on both tendons in the central portion around the fibula. This will never succeed. And repairs of two tendons will always scar, and repairs of either tendon done in the area around the superior retinactum will always be liable to fail. And this is entirely non-viable and requires an allograft. Here's an example of a patient whose surgery resulted in this giant scarred monotendon, which is not only unrecognizable, but completely scarred down. Now, one option would be to use a flexor tendon, in this case, the FDL, to substitute. But what I want you to see anatomically is that the muscular tendons junction on the FDL or FHL is too distal to be sufficient in most of these severe tears of both peroneal tendons. So here, the FDL is pulled through the fifth metatarsal, but it's still necessary in order to get above the area of the destroyed tendons to add an allograft to get this to heal, because this is non-viable tissue above the tendinous portion of the flexor. So here, in addition, an allograft is added. After doing this, it became clear that it would be easier in cases of tears of both like this patient to simply do the allograft itself. And the key surgical point is that the fixation of the allograft, which is done through a drill hole with a biotinodesis screw and suturing to the local tissue like the brevis stump, has to be done first to rigidly anchor it. Second, the retinaculum has to be reconstructed to get the shortest pathway of the ultimate reconstruction, because it must be as tight as possible. And third, that when the proximal anastomosis is done, transferring the brevis and lung together and both to the allograft, the hind foot has to be maximally everted and everything has to be held under maximum tension. In addition, I pre-stretch all things involved, both the allograft and the native musculotendinous units. Jim, I need you to finish it up. That's it. So the last thing I'll show you is this patient who had an allograft, and here he is at two years post-op, and he is back to running three times a week. So my conclusion is that perineal tendon tears offer us the opportunity to do this complex reconstructive surgery in the context of revision and complications. Thank you. Okay, that was amazing. Thank you. All right, now we're gonna round out the session with Dr. Kodakia, who's at Northwestern. He's gonna talk to us about ankle malalignment. All right, let me share my screen. All right, thank you all very much. So you've had a lot of scientific presentations based on fact and data, and now you're ready for a wild ride. There is not one ounce of data fact in this talk whatsoever. This is a lot of experience and really messed up things. So these are my disclosures. I also am lucky enough to be on the board. I didn't update it, because I forgot about that. So the format, This is a case review with my experience on all these cases. My task was bad deformities and what I did for them in revision. There was no fundamental basis for us for this talk. And when you look at the bottom here, it says trust only in the force. And so for those of you old enough to remember the original Star Wars, basically what Luke did, he took off all of his guidance and just believed in himself. And that's what this is, because all the stuff that you've listened to so far helps on a theoretical basis. But at some point you just have to do and trust that you know what you're doing. And I don't use many lines, data, articles, because it's not helped me as much as I thought it would in the past. So I may be wrong, but this is just a thought of how to do things. Because you, as a surgeon, you know if it's curved or angulated, make it straight. And that's really surgery in my opinion. So non-union subtalar fusion is first. I've had a lot of struggle with this. I think we all have. So when you get these, we try to do the same thing over and over. This gentleman presented with three times failure with subtalar non-union. You can see it's collapsed. It's a non-union loss of height. Talus is now declinated in the wrong direction. So that's a huge problem. But how do you fix this? Well, if you look at the CT, you see the problem. He's in valgus. He's subluxated. There's no talus left. You could do a standard bone block and try to get him out to length. But the problem is fixation. We talk about fixation and putting screws. The problem is that talus is missing. So how do you gain fixation? Well, in my opinion, just take the talonevicular joint and call it a day. So you do a bone block. You do a vertical approach as everybody talks about. And you got to crank that sucker back out of valgus and get your height. And always check that axial alignment. When I was younger, I would always fool myself and tell me, oh it's pretty good. It's pretty good. It is not. If it's not straight, it is going to give you a problem in the future. It'll give you valgus, like Casey showed with one of my cases that once she showed, she never showed the end case where it went from bad to worse to super ugly. And so things get a lot worse for you. So vertical incision, get it to neutral, and then take the talonevicular and CC joint. We theoretically say that we may lose some motion, but it doesn't. There's plenty of data out there that shows when you lock the TN, you gain significant stability of the subtalar joint, and you need that in a case like this. And these patients are asking you to go on uneven ground, grass, gravel. That little bit of leftover hindfoot motion doesn't bother them. Take the rest of the hindfoot. It functions as a unit. It'll let you get it to heal, and then be done. This is round four, round two, whatever it is. They don't want to see you ever again. And then it heals. There it is at six months out. Any kind of fixation you want to do, my conflict of interest is valid throughout this talk, but it doesn't matter. Use whatever you want. Just get it to heal. Don't stick to staples or screws or plates. You have lots of options out there. Use everything you can. And then they heal. You get the height back. It still looks ugly. Maybe we'll need an ankle replacement in the future, but for now the patient did really well, and you delay that ankle replacement. Getting a fusion does not count as a victory. This is a lesson that I've learned. This is not mine because this is terrible, but this patient had a TTC fusion done for ankle arthritis, and you can see it's in Aquinas and Varus. And you may convince yourself on the AP it's okay, but if you look at the mortis, you can see the foot is in Varus, foot's in Aquinas, and this patient was pretty upset and angry. And if you look at the CT, they achieved a fusion, but it's not a fusion that you get a blue medal for, a blue ribbon. You're still a loser because you did not do this patient any justice. I've done this too. So how do you approach this? Well, you've got a rod in place already. You have to change the way you think. To re-rod something that already has a large rod in may not be the best option. Different rods, different modes of fixation, maybe you could do that. In my opinion, when one type of fixation fails, I kind of say, well, maybe I should do something slightly different. In this case, to really correct this, I felt I would go lateral because she's in Varus. So I did a valgus sizing osteotomy, fixed it with the staple, prepared the subtalar joint, and then put some biology in there, and then use a lateral plate to really hold her back into valgus. And I did a dorsiflexion lateral closing wedge tibial osteotomy. And you really have to go significantly aggressive on these patients. You could argue that I don't have her out of perfect equinus. I think it's pretty good. I've seen her every year now for a year. She's happy. But you have to go aggressive. And if you've already got a large lateral incision, just put a large plate on there. It's not a big deal. And you avoid getting into trouble with going through an old hole. If they had a plate before, maybe consider a rod. Maybe if they've already had a lateral plate and a rod, you can go to the back and do posterior fusion. You have to be able to adjust how you do things. Don't get stuck. I like to do rods. Clubfoot, I think, is a hard thing to deal with. And so this is a patient that had a prior triple for a clubfoot. Clubfoot, I think, are one of the hardest triples we do because nothing moves. So in this case, this person came in. They were not happy with it because it's a clubfoot that was done mostly in situ. And a clubfoot, it's not really, it doesn't fit a cavus or flat, whatever. It's a clubfoot. So the medial column is literally translated dorsally. And it's not a supination. Partly it is, but it's also just translated. So as you try to correct, nothing goes. If you do clubfoot triples, you've got to be very aggressive with your cuts. It's like Lamborghini, Lamborghini style. And I'm sure I'm saying it wrong again. And you got to correct these people. So in this case, you have multiple options. You can mistakenly think it's the ankle. That's not the problem. You cannot just do something small. So in this case, you take out the hardware and I chose to do a lateral subtailor closing wedge fusion osteotomy to really get that foot out of valgus. If you do a lateral slide Dwyer type osteotomy, you create a massive zigzag and you're limited by how much you can correct. If you do a subtailor closing, you can correct the heck out of this thing. And so that's what I chose to do. And I'm a big fan of this. You can see now on the bottom, I've done a show part osteotomy, swung that foot into valgus. And what that does allow you to do is on your axial, which is every, every operative case for triple, the axial is the key to the game. That is now a neutral may argue tiny bit of errors, but it's pretty much a neutral. And I can keep taking bone out laterally until I'm happy. Once I get that in place, then I can swing the show part right around. And you can see the foot still ugly clubfoot are ugly from beginning to end. But the main job here, you can see on the x-rays here, I'm able to get that lateral column off the floor. Patient is now satisfied and happy because they're not walking on the lateral board of the foot. And now I do a lot more closing wedge, opening wedge osteotomies of the subtailor joint versus these Dwyer's and things that were described 25 years ago, because those are insufficient for very bad deformities for mild ones. They were great. But when the foot's really stuck in various of August, you've got to just start from the beginning and go big. Or I realized I just won't do their surgery anymore. And it looks pretty good. So cave is light. I don't know how people classify cave is anymore. I classify as cave is light and cave is bad. In my opinion, that's all there is. This person had a bad cave is, but they tried to cave is light operation, lateral osteotomy, first empty dorsiflexion, osteotomy with some sort of screw that was placed incorrectly. And what you can see is that it doesn't do anything and the ankle still bad. So he came in again, dissatisfied. So Wolfram Lenz taught me this long time ago. He's a smart guy out of Germany. And if the foot's really rigid and cave is, sparing joints that don't move do not give you any benefit. We do it out of principle because we don't like to take joints down. But if the joints are stiff and rigid, if you really got a bad deformity, fuse them. It's really the best way, not the only way, but the best way to get a correction. So I just revised everything knowing his ankle is going to need a replacement. You do more soft tissue release. Stacy talked about doing lateral longest to brevis for brevis to lungs, depending on the problem. I love that tendon transfer. It's two centimeter incision, minimal morbidity, and it helps a lot. So this is stage one. So you do a triple and you really swing the foot around. You ignore the ankle for now. So you look at that lateral x-ray. That's a really nice correction of his deformity. Get that foot where it belongs. And then now you go back in and you can see the correction. It's finally a foot. And then you give him a total ankle. And now you can see here he's walking at about a year. He's like three years out from the right side. He didn't listen to me on the left side. Some, another surgeon didn't listen to me on the left side, said I was too aggressive, went to New York, had a cavus light on the right side, came back again. I yelled at him for letting somebody else do the left side. Revised it the same way again on the left side. So you cannot get away with a bad rigid foot and do osteotomies. This is a severe pespinovalgus now. So these flat feet that come in with their deformities, these are hard. I hate this patient because they're sloppy. So it's not really rigid. It's so sloppy that if you look here, the calcaneus is slid underneath the fibula and barely articulating with the talus. So you get like as a Sazer talks about, you have that middle medial facet or middle facet visualization of, and this is 90% subluxated. So this person needs a subtalar fusion, but really you need more than that. You want to really correct this person hard. So you do a medial approach, swing it back in place. Don't forget the lateral tendons, always release laterally, longus to brevis, I mean brevis to longus, cut the TAL, lengthen it before you try to start putting the foot back. When I was younger, I tried to put the foot back and then decide if I need tendon lengthenings. That's backwards thinking. These people are so deformed. Give yourself a chance, lengthen laterally, lengthen the quinus that allows you to put things back in place. Get your axial, get your APs and get that foot back where you want it. Hold the subtalar joint in place, pronate around, take the CC. I'm not a big medial dipple person for real deformities. Medial dipple is for mild flat foot that's flexible. When you got a real problem, CC doesn't do anything. Just take it and get that lateral column up so you can pronate the medial column down. You do not want to end up with a supinated foot and not one patient's ever come back and said, man I wish my CC joint was more mobile. I needed that two degrees that are left after my hind foot fusion. Anybody can argue with me and I'll go toe-to-toe any day of the week. It is not a relevant thing to do. We do it because it's easy and with MIS, the CC takes 30 seconds flat. It's easy to do. Chris can tell you he does MIS for everything. It is no longer, it is no longer an issue. Year out, you can see everything looks pretty good. Ankle did not go back into valgus. That's case he talked about. They will find a home and the NC collapsed a little bit, but you don't care. Foot's planted great. We're not going to fuse the whole medial column of the foot. It gives you some stress relief off the deltoid. The case that she showed, I fused the entire medial column later, made his ankle way worse. So try to leave some stress relief if you can. You're not going for perfect x-rays. You're going for a planted great foot and pain-free. This is a valgus malunion. So if you're going to do revision surgery and you go to, you listen to a course like this for three days, you're going to go back home and start doing revision. You go big or don't do this to people. This person had a malunion triple. The person before tried to do a triple revision, but unless you are willing to do massive cuts, you will end up being dissatisfied. So ankle valgus, bad flat foot, still abducted. So you just go big. You do a large medial incision. You can see that there. I did an allograft deltoid reconstruction, medial closing wedge and pronate the foot at the same time. In this case, the subtalar joint was reasonably aligned. So I just did an MDCO and she's years out now and she's doing just fine. The ankle is not perfect, but corrected from pre-op and you can see the AP and the lateral. You want to get that lateral Taylor angle, that Taylor declination about that 20, whatever it is, 23 degrees. You're trying to get that talus in a nice neutral position. And if you get it that way and you lock the hind foot, they'll do pretty well. But big cuts and get it where you want it to go. You're not going to overcorrect. It's very hard to do and you can always dial it in. This is a case that I could not understand some weird surgery that was done to this person as a child. He came in and his whole foot hurt, obviously. So some cases don't fit the bill. That's not cavus. It's not flat foot. You know, what is this? No one really knows. He's got ankle valgus, subtalar varus, calcaneus is abutting and in the fibula and the calcaneus and talus aren't really articulating. If you look at the CT scan on the, on the right side. So what do you do for this? Well, he needs a triple, but the approach is slightly different. I did a medial approach and I did an opening wedge from the medial side. So bone block was placed medially, but large immediately because he was in varus, but I translated the calcaneus back underneath. And so that allowed me to get the correction of his hind foot. Again, massive cuts in the show part joint and then rotate his foot where it belongs. And you can actually make the foot kind of look like a foot. And there it is at six months, the CT scan, he was lost to follow up after the CT bone block healed, he was walking okay and went on his way. So ultimately I can tell you what happened after six months, but it does heal. You can get the alignment. And when it's a weird looking foot, you think about it in principle, just each aspect, the hind foot was in varus, but laterally translated. So you have to translate it back immediately, but then put a wedge in to correct it out of varus. To do that all without a block can be very difficult because it's hard to take differential cuts from the medial side. So that was my cheat. And then always take the tail and avicular and the CC joint and we spared his ankle in this case. So he will get ankle arthritis, but he'll be okay for now. And this is the last case. So deformity, and I've learned this from Chris and all the MIS people out there now that there are some times now we really should lean on MIS and it's changing my practice a lot. So deformity is one thing, but patients are another. So I have a lot of these types of patients that are near death and want their foot reconstructed and you don't know what to do. So the 82 year old gentleman, he has some heart failure, lymphedema. He says, I cannot be non-weight bearing. And what do you do? I've been managing with steroids for four or five years. He says, I cannot walk anymore. So you can relegate this patient to a BKA, a wheelchair or something, and you can't cut his skin. His skin's terrible. So you try some stuff, you learn from others, you listen and you try stuff. So you can see here, MIS has made a huge change because we can do crazy things that I could never have done five years ago. So I thought, well, I got this burr and I got a nail. Let me see what happens. And you can see the deformity here, bad varus. You can't just swing it around. It needs a TTC. He's not amenable to an ankle, obviously. So I did a small lateral incision. And when I see deformity in the ankle, severe, I always do that medial malosteotomy first. You try sometimes just to differentially cut and leave the medial mal. The problem is it's hinged and stuck medially. It will not swing back into valgus. So you don't want to just cut the deltoid. That's not ideal. So kind of first step is for me, TAL, medial malosteotomy. And then now I'm ready to go. I made a small one centimeter incision laterally. I marked out where I wanted to make my cut and then took that burr and I went to town and destroyed everything laterally. Check your lateral because the anterior aspect of the tibia is sometimes easily missed. And you just keep going until it gets where you want to go. And then you can see here pre-op and post-op. He's a year out now. He's doing amazing. I'll show his AP and his CT. So I did a nail, supplementary screws. I do like out of the nail or missing nail screws. I think they give you a lot of rotational stability. He walked from day one. I'm not telling you that's appropriate behavior, but I knew what I was going to deal with. And I could translate him back. I destroyed that posterior tibia so I could get him back and line him up. And you can see here the varus before and you got him nicely aligned. And you can get really amazing results with MIS. His ankles healed. His subtalar pseudo healed. But with MIS, you can do more amazing things. And it just shows you that you're not relegated to an open approach. And there are no rules. The rules are you can do anything you need to do with all the tools that we have and just make it straight by whatever means necessary. And honestly, bad deformity is probably the easiest thing that we do. I think it's easier than bunions and lesser toes because they just want a straight painless foot. And that's actually easy to achieve. Or a second toe or a big toe that's cosmetically appealing and moves is the worst. I've almost abandoned doing bunions because I hate them so much. And so this is my philosophy. I've had this for decades in my office. There is no try. You do or you do not. And that's important because you don't try to help somebody. Either you're able to do it or give it up and have somebody else do it and really trust in yourself, which is what I really believe. Trust only in the force means you can do these things. You don't need a guide. You don't need 3D printing. You need a brain. You need a knife, a saw, and you can make anything straight. Thank you. Thanks, Anish. OK, those were awesome. Thank you guys so much for being part of this. All of you is really amazing. I'm going to jump to our questions from our audience first, and then I have like three pages of questions that I wrote down because you guys are awesome. So we can see what we can get through. So first, we'll go to Christina, I think, and then definitely welcome input from everybody else. Two questions for you. One is, when do you put in that intermetatarsal screw? At what point in the procedure are you putting that across? Well, as I said, first I put the first screw, then I do the hook test. And if I see instability, then I put the second screw in because it's easier. And then I put like the plate on top. So because then I can vary with the screws over the plate, it's easier. And then one other question about Lapidus here is, since you're not taking a wedge for your correction, the question is, does that not, as you correct your deformity, does that not gap the first TMT open medially? And if so, do you use any graft or just leave it alone? I think that's pretty much the question. Well, this is because we talked about over the last few years about these derotation of the metatarsal one in terms of doing the TMT one fusion. So if you derotate them, then you also can close the gap. So I don't put any wedges or allografts in there. So I just take the cartilage down, derotate the first metatarsal, and then I can fix it. Perfect. Okay. This next one is for Dr. Brodsky. What is the process? How did you sort of figure out the need for the paraxial MRI images to get rid of that magic angle effect? The most important part about the paraxial is not so much the magic angle, because it does not eliminate magic angle, which occurs at 55 degrees angle to the bore of the magnet and becomes in perineal imaging distal to the perineal tubercle of the calcaneus. The purpose is to get a perpendicular cut, because if you use pure coronal or pure axial, it's too oblique to evaluate the cross-section. And so I think, and then they just sort of said, how did you get that kind of study? I think the answer is we just sort of worked with our radiologists directly to sort of tell them what we were looking for. Yes. Yes, that's right. And unlike CT data, you cannot reformat the MR, so you must have the protocol. And the way technically to do it is to put the patient's foot on a wedge. Perfect. Okay. And then one more question from our audience so far, this one is for Anish. When you stage the triple and the total ankle, do you address the deltoid and lateral collateral ligaments at the first stage? And then I think it's a two-part question, do you ever do a calcaneal osteotomy plus a subtalar fusion with FDL transfer instead of a triple for some of those advanced flat foot deformity cases and when? It's a great question. I don't know what the actual right answer is. I don't think there is one, but if I do stage, I typically will do the triple for total ankle and I'll do my soft tissue reconstruction at the same time because the incision is there. So I'll make a slightly post-framedal incision over the course of the post-tip tendon for my triple. That allows me to do a synthetic ligament in reconstruction of the deltoid spring ligament. Laterally, I'll go reconstruct everything if I need to. Sometimes I won't go laterally to the entire case immediately if I am able to get into an MISCC, so I try to minimize dual incision if I can. If they're really bad valgus, I do my triple. I'll pin it from the top dorsal plantar and then if I don't think I've done a good enough job because no one's perfect, then yes, I will add a calc osteotomy at the same time to get that hind foot where I need it to be. If I just am struggling and the subtalar will not swing, then to heck with it. I'll quit and cry a little bit and then do the MDCO and nail it at the same time. So at any moment, you do a triple. If you cannot get the axial where you want it and you're done struggling, you can't do anymore because there's theoretics as we do on talks and there's reality, then pin it from dorsal plantar from the neck into the anterior half of the calcaneus, then you can break the heel, push it where you want and go from bottom top and finish it. And that's not a fail, it's okay to do that, but that's the algorithm that I have. Perfect, thank you. Okay, I got a question for Casey. And I think that you're gonna answer this and I'm never gonna have a problem again. The question is, when there is, how do we manage the valgus ankle with a flat foot? I mean, when there is some subtle mild valgus, you don't think they actually have any ankle pain, you say, oh, I'm gonna get this flat foot fixed with whatever I'm gonna do, a triple, a reconstruction, whatever it happens to be, and they come back and you say, man, I really corrected this, that was perfect. And now they're six months out and their ankle is completely tipped over. Like, how do we figure out who that patient's gonna be? How do we manage that? Yeah, if you have the answer to that, my life is much better too, cause I certainly don't. I think the big thing that I try and focus on is how flexible and loose are they? And so I, unfortunately, I'm not fancy enough to have in-office Petcat, but I'm sure for folks who do, getting that standing CT scan, and for me personally, I'm super wary of those folks who have those big, huge ossicles off the medial mal, demonstrating that that deltoid has had kind of repetitive trauma or may not be functional. I do have fluoroscopy in my office, so I'll throw them on there and see are they actually widening even more? Like, can I play with them? And they're compensating. We'll say I have gotten burned badly by someone who had a varus knee, and they had a valgus foot and ankle. I had done a triple. My partner then straightened out their knee, and they went from a somewhat balanced deformity to their ankle, just the knee had been preserving the ankle, so I would say really, I know we're foot and ankle, but stand folks up, look at all of their alignment, because sometimes something else is keeping them in check. And that person came in, and they looked neutral six months before their total knee, and then they were in 30 degrees of valgus, and that for me is making me nauseous doing a total ankle at that degree of deformity. I still will do them, but I lay a lot of crape. So I think it's trying to catch it beforehand. I don't do a ton of deltoid ligament reconstruction, even having been trained like you are by Mark Meyerson and Cliff Jang, who did a lot of that, because when I nudge Cliff, he tells me he's not doing a ton of it. And so if the person who wrote the paper isn't doing a ton of it, I start to get wary. I am more aggressive now than when I first started out at making sure I am not leaving people in valgus after correction. And I am more aggressive now than I was when I first started out at adding on a lateral column lengthening to anyone who has, like it used to be they had to be sloppy loose before I do a lateral column lengthening. I am now doing more, because I just haven't seen the same amount of kind of recurrence and transmission to the ankle when you have an aggressively corrected foot. And knock on wood, I think I am chicken. I hate bunions as much as an ish, and I've never had a bunion recur, which makes me think that's why I'm bad at them. I'm not aggressive enough. And knock on wood, I haven't yet had a flat foot that I've over-corrected, but I've definitely had them that I've under-corrected. So I'm trying to be really aware of that. And I think probably we have to put a neutral varus. You have to over-correct deformities, and it's uncomfortable doing that when you're fusing someone, and varus is always a sin. So not 10 degrees of varus, but there should be a whisper in varus or definitely neutral, whereas my brain wants to put them five to 10 degrees of valgus. It's a very difficult problem, and you're captive to your own audience and your own patients, your own complications. Sort of the over-correction and then having the patient come in complaining of lateral column pain is like the absolute bane of my existence. And so I'm very reticent to push it too far. Christina, I have just a question about lapidus. Just generally, can you just talk a little bit about intercuneiform instability? It is a problem that seems uniquely associated with lapidus correction for bunion surgery. I don't do much lapidus, and so I don't have problems with intercuneiform instability with my bunions. And so I don't fully understand it. I don't really get why it happens, why it should happen. And I guess the question is like, how often are you seeing it? How often are you going ahead and fusing that at your index surgery? What's the deal with that? I think it is the source of probably our Hallux Valgus deformity in the beginning, if somehow there's instability, because you can see it over the years that somehow it gets more instable and the empty one goes more in varus. So I see this, especially as younger as they are, the patients, the more, of course, mobility you have in the intercuneiform joint. If you get older, then of course there is a certain stiffness sometimes, which goes in. It's not like an osteoarthritis. It's more like a kind of stiffness, but also you can see this in 60 year old. So this is why I interoperatively tested. If you ask me how many times I do the intercuneiform screw, it's increasing because if you really do the hook test, all the time you have the screw in there and they shouldn't be then stable in the TMT1. If you have a 5.0 screw in there, then the TMT1 is stable, but it can only be the intercuneiform instability. And if you really do this, every time you see more and more instabilities, you detect interoperatively. So my numbers of intercuneiform are increasing. I was dissatisfied with an intermittent tassel screw because this really had loosening some problems. You can also have fractures and everything. So this somehow gave me too much complications in some patients, not in all, but in some cases. So now with this intercuneiform, it's really a nice thing to have. I have a sort of follow-up question to that. Are you prepping the joint routinely with these cases? Intercuneiform, yes. You can also, if you resect your soid arthrosis on the distal part, you can also put a little bit bone in there if you want. You prep it and then you put the bone in there. Yeah, I think that's important. That's even more important if you do intermittent tassels because it's very important to prep it, you know, and maybe to put some bone in there because the stability is only over the metatarsals. If you put the intercuneiform in, it's a little bit more stable and less loosening. But- How often do you think you see the joint actually fuse? Probably seldom, probably seldom, yeah. That's true, that's true. But if you do the revision, if you're talking about it, it's always when it not fused. So this is, yeah, otherwise you don't, the other cases you never see again. So, but you see a bony fusion in this case, it's seldom, yeah. Thank you, that's really interesting. Jim, I have a question. When you do your tenodesis procedures or your allograft reconstruction procedures, putting deformity aside, not thinking about the flat foot or the capoveris foot, are you just reconstructing the brevis insertion? Are you tying the distal longus into the brevis? What do you do? My tendency is to forget about the longus, almost no matter what. I just sort of reconstruct that brevis insertion. I let the distal longus fly and I don't think about it. What do you do and why? Is your question whether after resecting the brevis, we should move the longus to the lateral board of the foot? Yes, that's correct. 100% because you need the mechanical advantage. The brevis is the more powerful of the two muscles and the mechanically advantaged for creating eversion because of its insertion. So you must move it. Now, Scott Ellis and I think the young Conti just did a paper on this in foot and ankle in which they didn't move it over, but that's not my experience. And then just to follow up to that. So the other thing is, do you repair the distal portion of the longus to your distal tenodesis at the level of the groove? Do you sort of take some of that longus to its insertion and tie that into your brevis reconstruction or you just let it go? Doesn't matter what I think you do to the distal longus. Most important thing is to attach the longus under tension with the hind foot everted because every muscular tendinous unit has an ideal length. And if we do it in a lengthened or inverted position, won't function well. Same is true for adjusting the tenodesis in the lateral compartment. Perfect, thank you. Aneesh, I loved your talk and I always enjoy your pearls of wisdom. I always tell the fellows, I say, stop trying to reduce the joints, just make the foot look like a foot, which I think is what you're saying too. And so I just have a question about your wedge osteotomies through the subtalar joint. I'm always a little bit reticent to do much of a wedge through my subtalar joint. I'm always trying to get my correction more rotational or sometimes sort of a neutral bone block in there. I just worry that as you wedge it, I worry that you're tipping the weight bearing surface and tipping them off of the heel pad one way or another. And I worry that I'm gonna cause them heel pain. Have you noticed that at all? Is that your experience at all? Or am I just, am I being, am I overthinking it? No, no, but just to be clear, I only do the wedge resection in a revision case. I'm not doing these wedges in like a normal human being. So if you have a malunion and the hind foot's stuck in varus or severe valgus, the fat pad has followed the calcaneus in that case. So in those cases, I've not noticed it because you're swinging the fat pad back or theoretically where it belongs. And so I've not noticed that because I only do it when it's a malunion, when the calcaneus is angled in that wrong direction. Interestingly, if you just do an osteotomy in those cases, the fat pad's still jacked up. So if you have a very bad valgus and do a calc osteotomy, you may swing the alignment on an axial. If you drop a plumb line down the tibia to the calc, it's neutral, but the heel's still in valgus. They may be loading the medial side. So like for a regular flat foot that's mobile, I obviously do what you do, I rotate. In a cavus, severe cavus, I don't get rotation much out of these people, so I do more wedge resection. In a very rigid cavus, that's not a revision, but not a huge wedge. I'm just getting it cut a little bit so I can start moving things around. And I will cut all the way to the medial side. When I first started doing them, I did make a separate medial incision. I put a chandler there deep to the posture tip and slid all the way around to make sure I didn't cut the nerve and artery. Now I've got more cocky, so I don't do it anymore unless I'm worried, but that's a good way to start. And it's been amazing. It really has allowed me to do a good job where before I think I was putting up X-rays that I thought were good, and honestly they weren't. But I would definitely do it for like a regular flat foot. And then to go back to the lapidus thing, we did a study like 15 years ago, but we were too lazy to write it up and publish it. So when you have the medial and middle column, and we presented it years ago, and you fixate the medial column, because I saw the same thing everybody else did. You do a Lisfranc or a lapidus, the intercanafrome would pop. And I could not figure out why. So what we did was we took a cadaveric study with OptiTrack sensors, fixated the medial column, first TMT with the plate and screws, and then tested the instability of the intercanafrome joint. And what we noticed was there's more instability, more strain and motion at the intercanafrome joint after you fixate the medial column. So it's the actogenic stiffening of the first TMT that translate that stress to the intercanafrome, which God never intended to handle, and so it pops. So I always do the screw that Dr. Stuttenberg does for that reason. And that's my understanding. We're just too lazy to publish it. Awesome, thank you so much. I think we're gonna go ahead and close the session at this point. I just wanna thank all of our panelists. Those were outstanding. I learned a lot and I appreciate all of your time and spending your morning with us. And I'll toss it over to Chris, thanks. Thank you guys all so much, really amazing talks. And I'm looking forward to the next session as well on total ankles and I'll let Liz take over. Thanks to all the speakers in the previous session. That was great. I'm also really looking forward to this session on complications of total ankle replacement. So we're starting off with a talk by Lou Schoen on why does my total ankle still hurt? Morning. All right, so why does my, I don't have a total ankle, so it's not really mine, but I guess here it is. Okay, so here we go. So why does my total ankle hurt? And this was a presentation I put together with the help of some of my partners. Here are my disclosures. I am co-inventor of the Zimmer Total Ankle Replacement. Ray Walls is one of my partners at NYU Langone and he had some great studies that I wanted to include. I don't get a lot of spec CTs and so I put a couple of his cases in here as well. Here's Ray and here's his disclosures. He's a consultant for the Zimmer Biomed, but not the replacement, the bone graft harvesting system. This is John Campbell, my partner at Mercy Medical Center. And Byung Min, this is one of my most recent international fellows. He was head of the orthopedic department at Daegun Veterans Hospital in South Korea. And he helped put together some of the literature research and some of my cases. So first we're going to define what is a complication. Glazebrook and colleagues proposed a detailed classification based on the chance of failure. So low-grade complications can still lead to problems subsequently. So I thought this was important to put in and plus this relates to how these painful situations are reported. But low-grade complications are intraoperative bone fracture, wound healing problems, both could lead to some chronic issues. Medium-grade leads to failure less than 50% of the time. Technical errors, which we know could lead to long-term problem subsidence. Postoperative bone fracture can be a problem as well. High-grade leads to failure greater than 50% of the time. And these are deep infections, aseptic loosing and implant failure. This is Dr. Min there, sorry. Okay. So this is some of the meta-analyses that we looked at. But basically for total ANK replacements in this systematic review, the overall reoperation rate was 17.4%. And these patients had multiple problems and we will address these in this talk. So some of these problems include prosthetic failure with loosening or subsidence of components, wear or breakage of the implant, infection, superficial or deep, impingement, medial, lateral, anterior or posterior. All those can be at play when a patient comes in with chronic pain. You have to look at all those areas. Ligament instability could be also some tendon injuries as well. Avascular necrosis, periprosthetic fractures which can occur due to trauma, malalignment or just repetitive stress. Osteolysis where we start to get a resorption around the prosthesis. A neurovascular complications like nerve injuries specifically could be due to the block like the polyplateal block. It could be due to the tourniquet. It could be also due to surgery, direct trauma to the nerves. It could be due to neuropathy that patient's developing. So it may not be directly related to the surgery but perhaps a preexisting condition. Also they could have vascular problems, either venous or arterial injuries during surgery or subsequently that can lead to chronic problems. Biomechanical causes can also do it. Of course, malalignment of components leading to altered bone loading in the joint. So this is a study recently done and they just showed that there's definitely a learning curve but the incidence of complications in their study was 44.2%. And also again, the learning curve was emphasized and they thought that whether it was mobile or fixed bearing, there was no differences. There was lucency or cyst around the tail's component more frequently in the mobile bearing group. Malalignment occurred more significantly in the mobile bearing group and reoperations were formed in the mobile bearing group. So how do we work these patients up? Well, we do a history and physical, of course. That's what we always do. We look for on their history, pain, what's the character of the pain? Is it burning, shooting, radiating that nerve? Is it achy, throbby pain that could be vascular, could be musculoskeletal? Is it a pain that's related to activity? Is it pain that gets worse over the course of the day? Is it startup pain? What elicits the pain? What helps? Those are all important. Then on a physical exam, we look at the incision. We tap along the incision to see if there's an aroma. We palpate along the areas to see where they have maybe some impingement, medial gutter, lateral gutter, anteriorly or posteriorly. We do range of motion of the joint. And we look at the joint alignment and stability. And a neurovascular exam is always important. And I love to do a gait evaluation. Everybody gets a gait evaluation. It's cheap, it's easy, and it will reveal so much to you. Let's look at imaging. So we got x-rays. And this is probably, again, the easiest thing to do. You could get it right in your office. It's a no-brainer. You don't have to have any special equipment. And you can see osteolysis or loosening, malalignment, fractures, wear, and some component failure. And if that's not sufficient, you can get a CAT scan. If you have a CAT scan with MAR, mental artifact reduction, that's even better. You can look at the periprosthetic reaction. If you don't have MAR, then you may get some distortion around the implants, which may diminish the value of the study. Assess bone stock, alignment, osteolysis. We get a weight-bearing CAT scan. That's a whole nother talk. SpecCT can be very useful as an adjuvant to the regular CAT scan. You add a single-photon evaluation. And so you can see what is actually hot, what's lighting up. I love the MAR MRI. And you could look at the technique that we use, the Siemens machine CMAQ protocol, but there's also a GE machine Maverick protocol. My buddy, Ian Fritz, developed the MAR protocol for the MRI, and he did it off the ankle replacements that I sent him, so it's really fine-tuned. And he could look for soft tissue complications, tendon tears, impingement, infection, inflammation, bone edema, stress reactions. Everything reveals beautifully on the MAR MRI. And then of course, bone scan, you can look for infection, loosening, mechanical failure. So here's one of my cases going back almost nine years ago, a patient was doing well. I have him do deep knee bends starting at two weeks and he's doing the exuberant knee bends and he gets a little pop and I go, oh, that's what you got, a fracture. And lo and behold, he had a fracture, we fixed it. And that was the end of that. This is a patient with longstanding implants. You can see very clearly this implant failed. I didn't do this, but I certainly revised it. And you could see very clearly the patient had failed with a lot of loss of bone stock. So I did a fusion with a plate. Here's another patient, not mine, doing okay and then starts to have symptoms. I'm scrolling. So this is his CAT scan MRI. You can see. And I just go stop, right? You can see that's me walking myself through the technique. Anyway, so here you can see cystic formation above the tibia and below the talus as well, predominantly above the tibia that looked particularly worrisome. And this patient is being followed right now because the symptoms are not too bad, but this patient I believe will need a revision. This patient is another patient with a very obvious sign by x-rays of a failure with some cysts. This patient had the CAT scan and you can see beautiful cystic formation and the patient's deterioration didn't stop there. It continued to deteriorate. The implant collapsed further into the bone and then I took the patient over and you could see a lot of lucency and the talus component was sitting on the calcaneus. What to do here? Here's the video analysis of the patient. It's so uncomfortable to step on this right foot. Is that expected? Lots of pain. Here's her malalignment. Here's what we did. A total talus with a TM ankle, a tibial component. The talus was fused to the calcaneus and she's doing well. There's another patient with an implant failure. She had been very active. She had about eight years on it. You can see the numbness that I mapped out on her foot and she's having quite a bit of pain. Here's her deformity and here's the nerve stuff. Sorry, this is not her. Wrong patient. Sorry, sorry. Here we go. Yeah, there it is. Okay, so this I did a total talus, sorry, a bipolar. This is a bipolar ankle allograft replacement. Here it is immediately post-op and you can see pretty good incorporation and she did very well. And she's now about four years out or so. This is another patient. You could see the implant, this is pre-op, was malaligned. The components were malaligned. Patient was having pain. He had three revisions and then I converted him to a TM ankle and he's doing well. This is a patient with a previous triple arthrodesis. Her ankle collapsed further into valgus. Here's what she started with. Here's what they did and this collapsed, boom, like that. And here you can see the CAT scan showing the defects. I like the CAT scans because it helps me to plan what I'm gonna do for these patients. So you can see cystic changes underneath the talus. So this patient got a bipolar graft like the other patient you saw and she incorporated very well. When I do this, I'm getting bone stock to fill in the void. And even if the cartilage surface melts away as it always does, you have bone stock replaced. Here's a patient, this was when a raised patient and you could see the patient had previous total ankle, had came in and was had tender to palpation over the lateral gutter, also syndesmotic discomfort. He did some testing. You could see the spec CT and found that the patient had impingement. So he did a lateral gutter impingement, posterior tib tendon tenodesis, sorry, did a debridement of the sub-tail joint, took down the lateral gutter, cleaned it out, repaired the posterior tib tendon and did extensive ligament work. And the patient did very well, was pain-free. So instability picked up showing X-rays and the spec CT. Another patient with a implant that became progressively more painful. You can see that on this MAR MRI, the patient is developing some changes above the tibia and underneath the talus there and had no signs of infection, but was having a progressive difficulty with the implant. We were able to see, very nice, you could see the edema, the medial edema underneath the talus and above the tibia. Again, this is the CMAQ protocol. And these are spots where we expect to see some reaction. So we are following this patient and this is a metal artifact reduction that was done for the same patient. And you could see here pretty good bone stock around the implant. Patient had a bit of a cyst in the center aspect of the tibia and one centrally underneath the talus that we are watching at this point. This is another patient with ankle replacement with pain. You could see the lucency that was developing here. Here's the three-phase bone scan. And this is the spec CT, which I think is more demonstrative of where the patient was having the problems. So this is, again, a patient with loosening of the implant. And you can see the great uptake above the implant, above the rails, and also underneath, but most of it above the rails on the tibia side. And this is a patient on biologics. After six years, he had done great, rheumatoid arthritis. He was my patient and he had a UTI and he said he did really well. No problems. And then he started to have pain in his ankle. It was five months after his UTI. So here you can see an abscess that developed from the ankle replacement. Again, multiple years out, hit this area. I don't know why. And then it puffed out all the way posteriorly into the area behind the fibula. We could see the abscess there. I took him to the OR, washed it out, retained the implants because his implants were good. I saw that on the MAR MRI that the implant had great bite, except for on that medial side of the talus where I debrided it and put in some beads. So also for infection, you want to get labs, rule out the usual markers. These are things that we could do pretty easily. And patients who are suspicious for infection should have all the standard markers. If they have a cyst, you should always evaluate, is this evidence of infection? What's causing the cyst? Is it just mechanical malalignment or is there a problem with the poly? Impingement, really common. This is a physical exam that usually is confirmed by X-ray. And here I have cleaned out one of my patients. My most common reason to take a patient back to the OR is medial gutter impingement. Although we do it, when we see a patient with medial gutter impingement preoperatively, we debride it. But postoperatively, sometimes the bone grows. And so we have to go back in and do a debris month. They do pretty well three weeks off the foot and get going. Fracture is pretty common. I'd say about two to 4%. And generally we do recommend treating them if you see it. Other pathologies always need to be looked at because you have foot underneath the ankle that could go bad despite having a great replacement. Neurologic injuries are more commonly not recognized, but in this study, they found a 15% incidence of neurologic injuries. In the literature, they are definitely underreported. This is a patient who I saw who had a MAR MRI. You could see where the nerve was transected. This was not my case. I inherited her and she had a complete transection of the tibial nerve. Vascular conditions can occur as well. Don't forget spine and knee. So in summary, prosthetic failure, infection, impingement, ligamentous instability, AVN, periprosthetic fractures, osteolysis, nervoscular problems, biomechanical causes. All these things need to be evaluated with a systematic approach. Get your studies. Labs are easy. X-rays are easy. Get a video assessment of their gait. Then you get advanced imaging and you customize your treatment to the patient and long-term data is necessary for us to have better guidelines. Thank you very much. Thanks, Lou. That was great. Moving on, next we have Konstantin Dimitrokopoulos talking about managing the stiff total ankle. Thanks, Liz. Thanks everyone for the opportunity to present. These are my disclosures, which shouldn't relate to the topic today. You know, one fundamental truth, and this comes from an article back in 2013 by Mark Meyerson is that ankle replacement remains a joint preserving procedure today. And the biggest predictor of range of motion after ankle replacement is the range of motion that the patient has before surgery. There's many different ways to assess range of motion. Certainly clinically in the office or radiographically, but for the most part, and as it pertains particularly to research, maximum flexion and extension X-rays is what we utilize. And certainly there's a limitation to this. It's effort dependent by the patient. And this may not reflect a true active range of motion that is non-weight bearing, but it's the best we have. And it's also a way for us to be able to separate tibiotailor motion from what we call global motion or tibia to foot motion. And ultimately what's probably most clinically relevant is total motion, right? How much your foot moves relative to your leg. We know also that range of motion is important for patient outcomes. And this was a study from Duke that found a correlation between postoperative range of motion and patient outcomes. And so ultimately patients that have more motion after surgery are going to score higher in their patient reported outcome scores. And arguably they're gonna have a better function. I'm gonna highlight a few studies from this past year. Some of them are ours, and one from the Baltimore group. This was a study that we did and we really looked at a small cohort of patients, only about 67 patients. But these are patients who had range of motion X-rays before surgery, range of motion X-rays during surgery. So we did maximum dorsiflexion and plantar flexion, X-rays with fluoroscopy after the ankle replacement. And then range of motion X-rays, as I showed you, weight bearing after surgery. And the fundamental question was, how much of the motion that you have during surgery do you get to keep after surgery, right? Ultimately, what is your goal of the range of motion that you wanna achieve during surgery? And how much of that do you get to keep? And what we found is that of the total motion, tibiotalar motion, okay, so tibia to talus, you get to keep about 65% of your motion after surgery, at least in our study. But most of that loss of motion, right, came from loss of plantar flexion. So interestingly, the majority of the dorsiflexion that was achieved during the surgery was maintained after surgery. One variable, confounding variable in this study is that a large percentage of these patients had an Achilles lengthening. And this was a time when I was doing a lot of Achilles lengthenings, really trying to maximize dorsiflexion and really trying to minimize bone resection. And I think that in our study and in other studies, and I believe, I think Lushon has a study that shows this as well, when you lengthen the Achilles, you lose plantar flexion. And it's unclear exactly why, but it certainly has been found to be true in a number of studies. This was a study that we did looking at the joint line. And the concept is that in ankle arthritis, there's erosion, there's erosion of the distal tibia as well as the talus. And for the most part, the tibia tends to erode more than the talus. And so for most patients, there's an elevation of the joint line after, with ankle arthritis. And ultimately restoring the joint line, so dropping the joint line down, it should be a goal of ankle replacement. And the more you're able to do that, the better your motion is going to be, both in terms of your dorsiflexion motion as well as your total range of motion. And this is something that we showed in our study of 150 patients. And this is also something that Amanda Fletcher, when she was a fellow with the group in Baltimore showed, is that when you restore the joint line, you're gonna have better range of motion, dorsiflexion and total motion. And in our study, we also looked at patient reported outcomes, and those were also better when you restore the joint line. And following these two articles, they were actually back to back in FAI, Mark Easley and Albert Anastasia wrote a nice commentary, sort of commenting on this, and also just looking at big picture, where are we with range of motion after ankle replacement? So I would encourage you guys to review that if you're interested. Now, just because someone's stiff doesn't mean they are not going to benefit from an ankle replacement. So a patient comes to you with post-traumatic ankle arthritis, they hardly have much motion in their ankle. That doesn't mean that we should just automatically fuse those patients. Because as you can imagine, patients who have less motion are going to in many ways benefit more from an ankle replacement. So their gain, their relative improvement in their gait parameters, this is a study by Dr. Brodsky, showed that those patients who were stiff had a greater relative improvement in their cadence, their step length, their walking speed, their range of motion, and the ability for the ankle to generate power. So just because someone's stiff doesn't mean they won't benefit from an ankle replacement. This really gets to the question of how much motion do we really need to really benefit from an ankle replacement? So in my mind, what is the reason that patients are stiff after an ankle replacement? Well, as we're talking about, a lot of it is because they're stiff coming into it, okay? A lot of it is the fundamental changes that are happening over many years as patients develop ankle arthritis. And a lot of that is the soft tissue envelope. And I emphasize to patients, ankle replacement will preserve your motion, but it will not restore your motion. And in some cases, it's inadequate bone resection. And this might be a little bit controversial, but a lot of times we're minimizing our bone cuts. We wanna preserve bone for the revision. Many of these patients are young patients, and we're thinking about what's gonna happen in 10 to 15 years. But ultimately, if you don't take enough bone away, it's very hard to achieve balance in the ankle. It's very hard to get the motion back. Why do we minimize our bone resection? Well, as we were saying, oftentimes we wanna minimize it on the talus because there's not a lot of talus left. But if you take less talus and more tibia, you're elevating your joint line. And a lot of times you're gonna get hung up in the malleoli. I think those patients are also more likely to have gutter impingement. A lot of times you're trying to tension the ligaments. Okay, so we have an unstable ankle, we wanna avoid doing a brostrom, or we have a valgus ankle with a flat foot and we're worried about the deltoid. So we're gonna minimize our bone cuts. But when you have asymmetry, so when you have one side of the ankle that is loose and one side that is tight, simply putting in a bigger poly is not the answer. So in those cases, you have to consider repair, reconstruction of the ligaments, or maybe additional soft tissue releases to achieve the balance. And I think sometimes there's a tendency to say, well, I'll just put a bigger poly in and it's gonna be okay. In fact, you're overstuffing the joint. Check your PSI plans. Now, I do a lot of instrumented total ankles. I don't use a lot of PSI in my practice today. But for most people, the default choice is to under-resect. Most people are under-resecting either the tibia or the talus, and in some cases, a little bit of both. But just because that's your default doesn't mean that should be for everyone. And so there are gonna be cases of a patient that is very stiff that you wanna take a full resection. So again, just be mindful of that as you're processing through your cases and looking through your PSI plans. Implant sizing is important. This gets to a little bit of the gutter impingement. And I tell our fellows, the talus component is almost always, not always, but almost always one size smaller than the tibia. So if you're gonna put a talus that's gonna match your tibia, you have to be 100% positive that's the right size because typically it's not. And if you're oversizing your talus, you're gonna get gutter impingement, and that can certainly lead to stiffness. As I mentioned, inadequate gutter debrimus, or you certainly wanna remove any bone in the lateral gutter, in the medial gutter. A lot of times bone in the lateral gutter, you have to make a separate incision. The only way to get to that bone is to take down the lateral ligaments, remove all of the bone from the lateral gutter, and then repair those ligaments. And a gastrocnemius and Achilles contracture. And though I've significantly decreased the number of times I do an Achilles lengthening, again, it's never, never. So there are gonna be cases where you have to do that. And if it's necessary, it should be done. So I'm gonna share with you two cases. This is a 57-year-old woman with post-traumatic ankle arthritis. Now, I don't have pre-op range of motion, but you'll see my point illustrated anyway. So this is her x-rays before surgery. Here's her intra-op x-ray in a neutral position. Here's her maximum dorsiflexion. Again, this is in the OR before closing the incisions. Maximum dorsiflexion. Maximum plantar flexion. And a total motion, tibia to foot, of 43.2 degrees. So that's total motion, tibia to the foot. So I'm feeling pretty good. I think I did a great job. Now, here's her one-year x-ray. Okay, so this is basically instructing the patients to stand neutral. This is asking the patient to stand with maximum dorsiflexion, so they bend their knee. This is asking the patient to stand maximum plantar flexion, 28.1 degrees. Okay, again, we're not comparing apples to apples. One is supine in the OR, one is standing. Here's the patient and her AP of her ankle. And the complaint at one year is stiffness. Her chief complaint is stiffness. My ankle feels stiff, my ankle feels stiff. She's also having medial gutter pain. And you can see there's some ossification in the medial gutter. Now, in these cases, I do get advanced imaging. I think Lou showed you some of that. And certainly in this case, I had a CAT scan, and often I also get an MRI. And the reason I took this patient back to the OR was for pain and was for gutter impingement. And I think ultimately that is, if you're going to take a patient back to the operating room, if the chief complaint and only complaint is stiffness, I think you're gonna probably get into trouble more than you're gonna really help the patient. Okay, so we went back to the OR for pain, but she's complaining of stiffness, complaining of stiffness. So I'm gonna do the best that I can do to get her more motion. So in this case, here's her X-ray with maximum dorsiflexion and maximum plantar flexion before I do anything. And in this case, I did an anterior approach, I removed the poly, cleaned out the medial gutter, and then I did a posterior medial approach and went around the back and released the posterior capsule. So two incisions. So here's her improvement in tibiotailor dorsiflexion, intra-op. So we've got about another 10 degrees and about another nine degrees of plantar flexion. Okay, So again, I think I did a great job. Now here's her ankle four years later from that revision operation. This is maximum dorsiflexion, this is maximum plantar flexion, and global motion is 25.8 degrees. And we're not gonna talk about the fact that at one year, it was 28.1 degrees. So ultimately, I don't think I made her any better in terms of motion. Now, thankfully, the gutter pain is gone, and so her pain is better, and she's happy with the result, so we don't need to do any more surgery. But in terms of improving the range of motion, I was not successful. Here's a 46-year-old man with hemophilia. He's nine years after ankle arthrodesis, and his chief complaint is subtalar pain. Okay, so again, this is slightly a different topic, but similar. We're gonna do a takedown and do an ankle replacement, and try to save the subtalar joint. And you can see here the gutters are completely cleared out, and here's my dorsiflexion, and here's my plantar flexion. And I'm thinking, you know, I did such a great job, and I really helped this patient. And here we are, one-year post-op, maximum dorsiflexion, maximum plantar flexion, 22 degrees. So from the OR to one year, half of the total motion, from tibia to the bottom of the foot. And here's the patient, four years post-op, maximum dorsiflexion, maximum plantar flexion, total motion, 20.6 degrees. So we've lost some. And when you look at the ankle, and you compare it to the intra-op, you basically see complete ossification of the gutters. Basically, he's pretty much fused around his total ankle. So is there future hope? Well, I think improvements in soft tissue handling and healing will allow us to begin motion right away after surgery, right? We're all worried about the incision. We're protecting these incisions and splints. Patients are not moving on post-update one. Best case scenario, as far as I know, unless anyone's doing something different, we're moving on typically two weeks after surgery. We need improvements in initial stability and fixation to allow earlier weight-bearing with motion, right? So some of us will allow weight-bearing right away, but we're doing it in a cast, we're doing it in a cam boot, we're not allowing motion and weight-bearing. Well, we need stability, right? We need healing. So we need to make improvements with that. A lot of my patients worry about where are they gonna do their physical therapy? And they want somebody who knows and has special knowledge of rehab after ankle replacement. Well, I don't know of any specific rehab protocols after ankle replacement. I mean, we really don't do anything, as far as I know, special for these patients to get them more motion. So maybe there's something more that we can do. And maybe we can consider modalities like blood flow restriction to minimize calf atrophy post-op and improve strength. This is an area that one of my colleagues, Dr. Dracos, is passionate about and is studying with Achilles ruptures. Maybe this is something we can do for our ankle replacement patients. So in summary, stiffness is challenging. It's often dictated by preoperative motion. Focus on factors you can control. Set appropriate expectations, right, with patients. And consider prospective studies, really, for us to better understand how we can begin to restore motion after ankle replacement. Thank you. Thanks, Konstantin. That was great. Our next talk is from Karl Schweitzer from Duke on intraoperative problems with total ankle arthroplasty. Karl. All right, great. You guys hear me okay? Thanks, Liz. And thanks to the other folks participating. These are my disclosures. Probably only relevant to showing some total ankles related to Stryker. When I try to break down this talk in layman's terms, what are we talking about? Interop problems. I broke it, I cut it, I tore it, I put it in crooked. I cut too much out. It's still crooked. It's still loose. I ran out of plastic. It's tight and it doesn't move. So when you sort all that out, and what I'll focus on today is mostly iatrogenic problems in the OR, such as fracture, nerve vascular injury, tendon injury, and instability. This can turn into quite a lengthy talk, but I'm gonna focus mostly on the top items here. So why care about this? We really talk the least about this topic. And as someone who's probably done 300, 250 ankles now in practice and 200 or so in training, and everyone on here probably does total ankles, we all know that nobody bats a thousand. We also know that most of these problems are preventable. And so we should really focus on those items and listen to Ben Franklin here at the bottom. We know there's a lot of different etiologies to this. Your flight plan, how much pre-op planning did you do? Pre-operative optimization of the patient, patient selection, that's really critical. Can you use PSI to help as well, or review cases with your partner? Surgeon experience plays a lot into this. How much have you seen? Can you get yourself out of trouble? Your ability to deal with deformity, whether you stage it or do it all at once. Recognizing patterns, there's definitely some of that in total ankle when you see patients preoperatively, kind of knowing how certain things are gonna behave. And then communication with your OR team, anesthesia, or even industry and what you might need for the case and what additional plans might come into place if things don't go as you thought they might. So we all know there's certainly a learning curve with total ankle, whether you call it 10 totals in practice or 20. We know that generally the more you do, the better you get at them and the more you see and the more familiar you are. So things that initially were hard become easier and then ultimately your patients end up doing better. When you look at one surgeon's experience with their first 26 total ankles, you can see we break things in the OR and that was probably most common in this study, but didn't have a lot of nerve or tendon injuries. These happen. I've had one and these always stick with you. I've had one in my 10 or 11 years of doing total ankles in practice. And so that can certainly be difficult to deal with because it's not something we're used to having to repair. If you look at database studies, this is out of our institution, just looking at submissions to the FDA in terms of failure and adverse events with total ankle implants. You can see they included a lot of different total ankles here and certain ones have certain higher incidences, at least reports of problems. And when you start to look at that, realize these aren't all interoperative problems, but it's very specific to the system that you're using in terms of, are you using an external guide or using intramedullary referencing? What kind of problems can arise with that? I think it's important to kind of recognize that. I think Lou highlighted this study as well, and I'll just kind of go to the end. This is important to recognize how we classify these complications, but what's more important is how impactful are these to the patient? So while intra-op fracture, which had a much higher incidence with total ankle, it doesn't often lead to failure. And probably just because that's something we're used to dealing with, we can fix it. The patient can heal and move on with their recovery for their ankle replacement. But something like infection can be quite devastating. It occurs at a much lower rate at 1.7, but the failure rate or loss of the implant, that rate is much higher. So I think it's important to recognize the impact of what each of these complications can have. So when we started looking at fracture, you know, this can be the tibia, the fibula, the talus, the medium of this is we've kind of harped on so far is the most common. There's other variants of tibial fractures, which we'll go over. Fibula is less common, certainly, and that can generally be an iatrogenic saw cut or perhaps a fracture when you're dealing with fusion takedowns. The talus is rare. I had to ask, of the 10 partners I asked, I found one talus fracture that someone had that actually went on to heal without fixation. So, but when you're talking about the medium, I would recommend just put the screw in every time, just protect it. It helps interop, you know, if you're dealing with a stiff ankle or there's certain parts of a specific total ankle that you might be doing that might put the medium malignancy at risk. And it also certainly protects them postoperatively as they start to get more active and do more. I think it prevents that phase when they're getting out of the boot and they start to get that medial pain. You start to see the talus over the medial side. Ever since I started routinely putting screws in total ankles, I haven't had patients get that medial pain. So prophylaxing the medial malleolus, certainly better to ask for permission than forgiveness. The timing of placing the screw in surgery can be variable, and that obviously depends on the system that you're using. But really just think about what you're doing during the surgery. I know that sounds silly, but think about, you know, where you're stressing the medial malleolus. It might be helpful to have the screw up before you start impacting a big intramedullary base total ankle where the medial malleolus is already thin and you might have a chance of fracturing it. We know that certain patients have more risk for developing fractured intra-op and post-op, certainly those with osteoporosis or those that have a thickness measured at the tibial component around 10.5 millimeters or just less than 11 millimeters as Greg Lundin showed. Those that have inflammatory arthritis, a lot of cysts that could represent a pathologic impending fracture, and those with stress-shielded bones. So those that are stiff, perhaps pre-op valgus with a medial malleolus is stress-shielded, and as we highlighted, fusion takedowns to totals. This bone on either side has not seen much stress. And then intra-op fracture risk, certainly with the tibial cuts. You know, the more you move your tibial cut proximal or medial, you're narrowing that window of the medial malleolus. You have to be careful with your saw cuts and always be sure that you or your trainees you're working with are cutting perpendicular to your cut guides and you can get into trouble. I'll show a couple of cases in relationship to that. Bone resection removal, that can be a difficult portion of the procedure. It seems to either go really quick or it can take 30 minutes. So you just gotta be careful about levering with a ronger or other device on the medial malleolus. It's an easy way to break it. When you're impacting your tibial component, it's probably more relevant for stemmed or keeled implants or just patients with impingement. When you're trialing them, I've knocked the medial malleolus off while dorsal flexing and I hadn't had a chance to clean out the gutters yet. So that can certainly happen. And with fusion takedowns, the clean out of the gutters and reestablishing and re-cutting the gutters is critical in getting your wires and screws up before, much earlier in the case than you would do for a primary total ankle. Like I said, there's other variants of this at the tibia. So you can see angioplesiotomy, which can still leave the implant stable, but if it's more significant, you may put a rim plate on that. That's relative to hoop stresses. And you wanna be really careful when you're impacting the tibia. I tell the fellows, you gotta let the bone breathe, give it a rest. Don't just keep hitting on it. Paying attention to how the implant goes up. It can hit on a cortex and then you're just hitting against a hard stop and then the weak point will give. So again, really paying attention to what you're doing in the OR. I've seen some of these anterolateral rim fractures. Sometimes it's on the lower profile implants. These don't tend to be significant as I've, in my practice, I've seen them just heal without much fixation. And then you can get more metadiapsial fractures. These tend to come with more standard cured implants. And certainly when you're explaining larger total ankles, you can develop fractures as well. I'll come back to the case at the top right there with the tib-fib fracture. And this is trying to explain this and convert this to a fusion. Obviously this is a tough task and this is a long stem and it's healed solidly against the posterior tibia. And that's kind of what you get when you get it out after you have to make a cortical window. So these procedures can be fraught with complications. You have to be ready for them and be prepared for what's gonna happen. The lateral malleolus is certainly uncommon. Maybe with some of the fourth generation implants where they have this wider cutout around the fibula, you have to look out for that. And certainly recommend putting a screw up this side when you're doing a fusion takedown in kind of that rare case. The talus, as I said, is very uncommon, but I think with some of these newer implants where they have the flange, you take down more dorsal, tail, or neck, I think that that can put the tail or neck risk for fracture. And body fractures, I haven't seen too many of those, but I presume that would be more during, perhaps during implantation. Again, pay attention to bone quality, let the bone breathe, don't just keep hitting the implant down to get it seated. We looked at this at our institution. These were fractures that occurred four weeks out from total ankle, but I think you have to think about, was there something that happened perhaps in drop that may have led to this? And so it's important to kind of look at the distribution of this. I don't wanna linger too much on this, but we basically found out that you should just fix the fracture. Those that were left to heal, whether through immobilization or casting, just didn't do as well. And the implant stability is the most critical factor here in terms of whether you can just fix the fracture or whether you have to consider revision or perhaps conversion to an arthrodesis. The tailless fractures tend to be the most devastating. We also know that bone mineral density plays a role and you can look at houndstooth units, but in this study out of our institution, patients that had houndstooth units less than 200, or any patient that had an intra-op fracture had a houndstooth unit less than 200 and that houndstooth unit is predictive of a periprosthetic fracture. So what do I do? I generally protect the medium with this every time. Now, this one did not happen intraoperatively, but I was away the weekend after I did this, the patient was in the hospital waiting for rehab placement and something happened in their bed and they twisted in their splint and my partner got called and luckily he was able to help them out with this and took her back to the OR and fixed this and slid the plate up and tried to be as minimally invasive as possible. But sometimes, you have to be prepared to be a trauma surgeon as well with these. Now, this looks good. I mean, you can be high-fiving after this case, but you can start to really criticize or look at how I reamed, I put the implant more anterior, I widened my base stem and mid-stem and now I'm really up against that anterior cortex. And so postoperatively, you start to see this fuzziness and this lady came in with some vague pain. It wasn't enough to get her out of her shoe, but she was definitely hurting and this we were able to manage conservatively and you can see how this went on to heal in some recurve bottom, but clinically is doing well. And you have to be careful about your technique. You know, we put wires in all the time, particularly for PSI type cases where you're putting all these guides on. This patient had a stress fracture between these two little pinholes that I would otherwise not think much about, went on to heal without any type of malunion. We talked a little bit about saw cuts, the atrogenically to the fibula. This is one of my partner's cases that they sent me. And so what happened here is probably a little bit of over-sizing on the tibial component and this is already an implant that comes pretty far lateral. And then the fibula got cut and then when they were removing the tibia, the fibula actually came out with it. And I remember this clearly because I was out of town and my partner had called me for some advice. And we actually discussed using the tibial resection and reconstructing that as part of the distal fibula. And he put a hook plate on it and he sent me these films and says, the patient has done really well with this, but you know, this can be a quite devastating event in the OR if you haven't thought about this before, how you might deal with it. So in summary for the fracture stuff, these can certainly be prevented. You're not going to bat a thousand, but be aware of the systems that you're using and what the critical steps are and where things can happen or go awry. Have good surgical technique and always put that medial screw up. If fractures do occur, you want to assess the component stability, be aggressive and fix them as I've listed here. So in terms of neurovascular tendon injury, spoiler alert, if you cut it, do your best to repair it. You can look at some of the studies on the anatomy. The first thing you'll see on an anterior ankle approach is the branches of the superficial perineal nerve. And you always just want to be very careful to mobilize that. I'll usually draw it out like they did here with a marker just so the fellow and I can keep an eye on it throughout the case. But we do this a lot with wires and saw blades and osteotomes, and we don't think much about what we're doing at times, but these things can cause injury as well. And so here's the reported rate. I think a lot of this is underreported, but you can do a technique if you're worried about it or the patient's very scarred in or it's a revision where you make a posterior medial incision, open up the posterior tendon sheath, move everything posteriorly and use a ribbon retractor or other retractor to protect yourself throughout the case. And here you can see in the bottom right is this ribbon retractor. My one partner who's partially retired now used to do this towards the end of his career in primaries and revisions. But you can see these wires that we put in from the front, these are all dissections from the back. You can see tibial nerve injury, tibial artery injury, posterior tib tendon injury. These things aren't benign. You can see here with one particular implant system, what structures are at risk. So posterior medially, you have to worry, or sorry, proximal medially, you have to worry about the tibial nerve, distal medially, more about the FDL, and this distal lateral, perhaps more of the sural nerve. So these things you have to be aware of. And so in general, put it back as you found it. The case where we had lacerated the FDL and the tibial nerve, we explored it, post-remedially and repaired it and did it the best we could. We'll move ahead just to instability and soft tissue balancing. So for me, this is a series of checks. Is the metal in properly? How's the alignment, the rotation? Are the gutters clear? Is that preventing good tracking of the talus and the tibia? You want to think about their preoptiformity and how their joint is responding interoperatively. Is it too tight immediately and you need to do a deltoid peel? Is it also a little bit loose laterally? You need to consider a brostrum. And when doing that, I keep the thinnest poly liner in trial and place to keep the joint congruent and to snug things up as best as possible. But these things come up with other cases. All right, Carl, time to start wrapping it up. Okay, sorry. These come up with other cases as well. Certainly you can have instability when you're doing total ankles with total talus and there's different ways to deal with that. And medial instability is the most difficult. I'm just going to show a couple of cases here and get off. But this is a older man with bilateral valgus and pronated feet. And so, you can get yourself into trouble here if you don't get the talus up. You don't want to overcut posteriorly. So you want to dorsiflex in the frame here and also use a laminar spreader to minimize your resection as Constantine said. So you can see here the minimized resection and then also stabilizing the medial column so you have a stable construct. And that's what it looks like at two years. Just going to move forward a little bit. You can also decouple your cuts when necessary. So some valgus is really hard to get straight to do a couple of cuts. So sometimes you have to kind of do poor man's PSI and decouple here. But as you can see, we also cut into the fibula a little bit, not enough to destabilize it, but important to note. And as we're impacting the tibia, you have to pay attention to these sidewalls. You don't want that to tip your implant at the last impaction. So sometimes taking a reciprocating saw and debriding that can be very helpful. And this is the last case here. So a man that I tried to do all in one, a very bad valgus deformity, ended up having to do a little bit of a deltoid. He fell and came back in five weeks and had this. Also was dealing with wound issues, was from Ohio. And so I talked to him about just starting over. And so I did a closing wedge, derotational transverse tarsal osteotomy, put a spacer in, an allograft deltoid, came back and did his total ankle. So, you know, a lot of intra-op events can be prevented with preoperative planning. And now I've really moved towards patients like this, doing allograft deltoids, transverse tarsal, derotational osteotomies and fusions, and then coming back and doing their total ankle in the second stage. And this is done through reconstruction of the deep and superficial branches with an allograft, usually a peroneus longus. So I've really started to do that on some of these highly deformed cases. I'll finish there. Thanks for your time. Thanks, Carl. Those are some incredible cases. I feel like some of those cases gave me PTSD for all the problems that I've seen in the OR. For sure. All right, now moving on, switching gears a little bit, we're going to hear from Beth Gosden, who is arthroplasty at the Hospital for Special Surgery to teach us what total ankles can learn from a total knee replacement. Thanks, Liz. Let me just try to, here we go. All right, great. Can you guys see my slides? Yes, you just have to go in presenter mode. Okay, perfect. Well, I've certainly learned quite a bit about total ankles in the last few minutes here. So thank you guys for having me. This is going to be a little bit of a review of total knees. It's probably been a little bit of time since you guys have heard about our total knee experience. And, you know, I think that there's a lot of overlap, things that we can learn from you guys, just from seeing some of the designs and how things have progressed since I was a resident. So I'll fire away. I just want to thank a few people that have contributed to this talk, Dave Maiman, Tim Wright, and Brian Springer. So an important little disclosure here, I do consult for Striker. And I think the biggest disclosure is that I am a big fan of robotics. So we'll see that throughout this talk, but hopefully try to keep it relatively not industry specific. So I'm going to talk about the epidemiology of osteoarthritis, how it presents in total knee, and obviously the differences there with total ankle, where we've come from with the history of total knee, and then where we're going. So hot topics in total knee design and technology. So just as an overview, total knees, obviously, or excuse me, knee osteoarthritis is a much more prevalent disease than either hip or ankle OA. So knee affects about 15% of the population compared to hip is about four, and ankle is a lot less common. And just as a reminder for myself, as I presented this or prepared this talk is that really, it's post-traumatic ankle, post-traumatic arthritis that accounts for a lot of ankle problems compared to, you know, hip is a lot less common for post-traumatic as well as knee. So we're kind of starting from different points with our patients, of course, so it's important to keep in mind. And the volume here, total knee is just exploding in the United States and around the world. And a lot of this actually is one of our co-residents, Liz and I did residency together. One of our co-residents actually did a great study in residency confirming that a lot of that explanation of why knee is rising, obviously knee arthritis is more common, but also just obesity is a huge factor in that too. So it's probably why knee is rising at such a swifter rate compared to hip or, or ankle. And then obviously ankle continues to grow. And I think, you know, one of the big things when I'm preparing this talk, the difference that we have is, you know, knee surgeons versus ankle surgeons is that your alternative, your next best alternative arthrodesis is a whole lot different for the ankle joint, of course, than it is for the knee joint. So a knee arthrodesis while we do it is obviously very, very uncommon. It's really, really much more of a salvage procedure and obviously a huge impact for that patient's life if they need to go on to, to a knee fusion. So just, I think it's important to kind of learn from our history and design and total knee, although it's done over nearly over a million times a year in the United States, doesn't have that long of a history. So just 50s, 60s is when the first kind of more modern arthroplasty came out. So the gay par was one of the first and that was a metal on metal hinge. So obviously problems with that. Then the duo condylar came out after that. As you can see that design in the middle there had two tibial inserts linked with an anterior bridge. The total condylar is like kind of the, the predecessor of most modern implants there, but it really only allowed about 95 degrees of motion. And then these more modern implants came out. A lot of them were developed in the late 60s, 70s. So the insole Bernstein one was the first one to have developed the cam post design, which facilitated the rollback and increased flexion. That's the image all the way on the left there. And that was an all poly tibia. Interestingly, we still have all poly tibia is there a lot cheaper than our other options. They actually have great track record, but the insole Bernstein two came out after that. And that was the metal tibial component that had a modular insert. And it also introduced different levels of constraints. So the more constrained, the heavier box post mechanism to introduce more varispalgus constraint. And then really, I mean, most of our implants today look very similar to the insole Bernstein with, with minor differences. And then one thing that I think the ankle surgeons and the knee surgeons can agree on is I think still very controversial, whether cemented or press fits. And I'm learning more from you guys in this last few, few minutes about that, but press fit designs or uncemented designs are rapidly growing in popularity. I think in certain brands, over 50% of knee implants put in the United States last year were, were uncemented. And that is just kind of interesting phenomenon. We still have a lot of controversy over whether people prefer PS or post your stabilize, where they remove the PCL or cruciate retaining survival is a bit different. If you looked at these larger database studies there is potentially some benefit to saving your cruciate ligament and doing not having to cut a box. That's probably related to a little bit of bone preservation there. Again, remains really controversial and both are considered standard of care today. I think one thing that we've done, and I can't take any credit for this. This is many of many people smarter and wiser than me back in 2010 started the American joint registry. And I think this has been incredibly helpful for us and it's going to continue to, to add to our knowledge. So obviously a lot of other countries are, are a lot further along in their registry journey than we are. But since 2010, we've been, been collecting more and more data and out in last year, we probably have over 2 million joints that includes both hip and knee, but this allows us the ability to really see trends and to see what's working and what's not. So you can see the growth here, and this has really been a labor of love. There's really not a lot of incentive for, for institutions to contribute to this. I'm not sure what's going on on in the total ankle side of this for, for you guys, but I think if, if anyone's interested, we'd be happy to connect you to, to members of the AJR that have pushed this forward, because I do think it's been really, really helpful for our field. I think it's one of the big things that we were able to look at is the biggest reasons for revisions, which we've obviously are able to look at in smaller studies and in other countries' databases, but obviously there's some differences between the U.S. and other countries. So infection remains the number one reason for revision, followed by loosening, and then other mechanical complications. So I think if you guys look at the top of those lists of indications for revision, they probably are similar indications as what you get in total ankle, but interesting to look at in a large scale. And just to see like one thing that's come out of the registry that's really changed practice, or at least about to start changing practices, as I mentioned before, the cementless designs have become incredibly popular. And the data from the AJR has, has showed us kind of what we should be doing rather than what we want to be doing. So it's, it's fun to put in a cementless design, it's faster, and it's nice to use new technology. But what we can see here from these trends is that the population that really benefits from it are males under 65. You can see the yellow line is the cementless implant, and that outperforms the other implants in males under 65. But in females over 65, that yellow line has the highest revision rate. So that kind of makes sense. You know, these are osteoporotic, more osteoporotic people, they're fracturing more commonly, subsiding more commonly. So just something as simple as looking at design and having a registry to look at has been incredibly helpful for for simple things like this. So we're talking with, with Dr. Cody ahead of time about what's new in total ankle, it sounds like custom implants and guides. And I can see why, after seeing some more of your your surgeries in detail here in these last few talks, I think what you guys I think these knees are hard, I think what you guys do is incredibly more difficult. So I can totally see how custom implants would help on the on the knee side of things, it really hasn't gained mainstream popularity, there are still some surgeons doing them. I think it's mostly reserved for unusual deformities or to avoid specific hardware. In general, the philosophy that I went on was a resident we all trained on, I guess I'm getting a little bit older now, but it wasn't that long ago. You know, less than 10 years ago, I'd say like 99% of the knees that I did as a resident, we did mechanical alignment, where we cut at 90 degrees relative to the mechanical axis of the femur and the tibia. And then we soft tissue balanced around that to get a balanced knee. So that was John Insaw was really the designer of the modern knee and one of the godfathers knee surgery. So I think that this philosophy today is still valid, but the way we're approaching it is slightly different. So we still obviously are aiming for an incredibly balanced knee, I think that leads to patient satisfaction and decreases revision rates, but how we're getting there is different. So there's alternative alignment strategies that have become popular on the knee side of things. So kinematic alignment is one of those philosophies. And it kind of leads to some x rays that maybe don't look so pretty. But the goal here is to restore the knees natural anatomy and joint line alignment. And that just using caliper technique to take off whatever bone is there in very equal amounts. So if the joint line is incredibly valgus to start, the true kinematic alignment surgeons would leave the knee in an incredible amount of valgus. Functional alignment is a little bit more measured, where we're restoring the natural joint line and not going for a strictly mechanical knee, but we are doing this by soft tissue balancing. And this has gained a lot of popularity. So it's somewhat of a kinematic alignment with somewhat of a restricted approach. The functional alignment really needs some sort of technology to do an appropriate job of soft tissue balancing. And so enabling technology has evolved on the knee side of things for sure. So even as a resident, the majority of the knees I did here on the left manual instrumentation, extramedullary cutting guide for the tibia, intramedullary cutting guide for the femur, you're going for 90 90, you're going for a perfectly straight knee, which was actually, you know, this is relatively technology, you know, advanced technology compared to the freehand cuts that knees were done with originally. And then computer assisted gained a lot of popularity. Even when we were residents, we were starting to do this. So it's accelerometer based and still kind of most of these were done with the goal of mechanical alignment. And then more recently, robotics has gained a lot of traction. And so this is some of these are CT based, and some of them are just 2D based, but they allow for better and more accurate ligament balancing. And it facilitates these alternative alignment strategies. So while it's pretty easy to see or relatively easy to see with your eyes that you're cutting something at 90 degrees, it's a little more challenging to say that you're cutting it at four degrees of varus or two degrees of valgus. And so that's why I think most people that are adapting some level of kinematic or functional alignment are choosing to use some form of advanced technology to do so. So I thought this was interesting. This is just a hot off the press. We had our national meeting last week, AUKUS in Dallas. And every year for the past like 15 years, this is Dan Barry, who's one of my mentors at Mayo. He runs this AUKUS survey. And this survey is really popular. Everybody kind of likes to see what's going on with total knees. This was the percentage of surgeons that are using robotics in any form in their total knees, and only 38% don't use it at all. 22% are like me, nearly 100% using robotics, but the 62% are using it to some degree, which is a lot higher than hips, which is kind of interesting. And it's every single year it goes up and up. I just want to show, this is my partner's case, but this is just showing the technology that we're using. This is CT-based, three-dimensional planning, and this is him tensioning the knee during the case. I think one of the factors a lot of people don't want to use this is because they think it's going to take a lot of time. As you can see, this is just 29 seconds to do the soft tissue balancing and flex, basically stress the ligaments, excuse me, both in extension and then 90 degrees of flexion. And you can see the computer screen on the left there is capturing the amount of millimeters that is opening, so it's a lot more precise. And then here's getting that screen, and you can see in both flexion and extension, your gaps and what you're going for. So you can make subtle adjustments to the knee based on those numbers. It's just showing your preoperative alignment, and so it kind of gives you targets that you're aiming for. So like I said, it's pretty difficult to tune in one degree of varus with your eyes, but a lot easier with the robot and haptically guided sob. And you can see this, again, something that I never would have done as a resident. He's internally rotating the femur, which was absolute hearsay in residency for me, and now we're doing it much more commonly with these functional alignment strategies. So things are definitely changing. And then this is just the sob. I'm not going to show this whole video, but this just saw cuts coming in, and you can see he's got no assistance holding the retractors, just a self-retainer. And part of that freedom is that there are haptic boundaries that aren't going to allow you to theoretically cut any structures like your patellar tendon or your MCL. So it's certainly come a long way, I think, since training for me, and this is just the final showing that the robot potentially allows those cuts to be a little bit more precise and more perfect contact of the implant on the bone surface. And then also for me, what I like to see is that rollback. So very little evidence to show that this is actually occurring postoperatively, but at least in the operating room, this is what I'm going for, the rollback of just about a fourth, the posterior fourth of the tibia. So the femur is rolling back to that posterior fourth of the tibia, and that has kind of shown me that I like that amount of tension and flexion. So in conclusion, I think the total knee has more complex mechanics and soft tissue balancing compared to the hip, but it's certainly not as challenging as the ankle. And I think you guys would probably agree with me there. I think our targets in the knee, despite all these years and many, many tens of thousands of publications, our targets are still unclear. I think they're potentially moving towards more personalized or functional alignment and the utilization of robotics and navigation for data collection and linking this to outcomes is really needed and helpful towards this goal. So sorry to distract from the main topic at hand, but I do think this is kind of a helpful thing that we can share these ideas and hopefully steal some new ideas and things from one another. So thanks again for having me. Thanks so much, Beth, for that great talk. I think it looks like things have come a long way since I did residency, because I don't remember a lot of what you showed. So it was great to see. So anybody in the audience, if you've got questions, you can enter them in the Q&A box, and I will make sure to ask. And I think, Chris, you had a question for Constantine. Yeah, Constance. First of all, awesome talks all around. And Beth, first of all, thank you for joining us. I think one of the things that we really liked about this one is trying to get different perspectives from people outside of the foot world. So I really appreciate you joining. But Constantine, I was thinking about that case that you showed with the stiff ankle on the 28 to 25 after the revision motion. I assume that was total arc of motion. But have you looked at where the arc of motion is? Sometimes, do you think dorsiflexion is more important than plantar flexion? Do you think she was better? And again, I couldn't look carefully, but I just got the sense that maybe she had better dorsiflexion, even though she had overall less arc, if that makes sense. And what are your thoughts on the relative importance of arc versus where the motion is? Yeah, that's a great question. And I hope I'm not misrepresenting, but I think Duke has done probably most of the work looking at where the motion is occurring, whether it's in the ankle or the hind foot or the adjacent joints. I think ultimately, it doesn't particularly matter where the motion is happening in terms of the patient's perception of motion and probably also their functional ability. So whether the talonevicular or the subtalar joint is contributing to the dorsiflexion or plantar flexion is probably irrelevant in terms of how the patient feels or their ability to walk on uneven ground, go up and down stairs. One thing that we found in our robotic cadaveric study is that, you know, when you replace an ankle, the adjacent hind foot joints still function largely as they do in the intact state. And so in terms of the pattern of motion and also the range of motion, it's relatively the same pattern versus when you fuse an ankle, the adjacent joints, though they do compensate for that motion, they do it in an abnormal pattern and in an abnormal magnitude. So they do more motion than they normally do, and they do it in many ways in the wrong direction from heel strike to toe off. So an ankle replacement at least allows the adjacent joints to function as they normally do and to continue to compensate for the overall limitations that the patient has from the arthritic condition. So I hope that answers. In terms of me specifically in that patient, I don't get caught up too much into that in terms of when I'm assessing them. Ultimately, what I'm addressing at the time of surgery is the ankle, so I'm trying to maximize tibial tailor motion, but I do recognize that most of the motion is still happening in the hind foot. After you presented that case, I feel like you were sort of suggesting that you really can't improve the motion. I mean, is that something you would still do for somebody that comes in after an ankle and they're really unhappy because they're still stiff, but otherwise they're doing okay? Is that still something you would offer them another procedure to try to improve their motion? To be honest, I think I try not to. So if a patient says to me, I have no pain, but my ankle just feels stiff and I want my ankle to bend more, I try to discourage them from surgery. Now, at the same time, if you never try, how are you ever going to get better? And so if, for example, if patients are not plantar grade, so let's say that they don't come to neutral, I think that's a great indication to intervene. If they have five degrees of dorsiflexion and 10 to 15 degrees of plantar flexion, and their expectation is to match the contralateral side, then I would strongly advise not to perform a surgery. So I think it just depends on the context. But there are cases where I will still try, particularly if they're just in a non-functional, non-plantar grade situation. Good. I've got a question for Lou also. So you showed a bunch of different imaging modalities, and you talked about all of them a little bit, but what are your thoughts on the benefits of SPECT-CT versus a metal artifact reduction MRI? When would you favor one over the other? Yeah, great question. We just got a SPECT-CT at Mercy and so we weren't using it routinely. Now we're using it a little bit more, but I've seen patients come in with SPECT-CTs and I was a bit disappointed because a lot of things lit up that I didn't think were clinically relevant, zones that were hot on the talus, that weren't tender at all, that looked fine on X-ray, that even looked fine on CAT scan. And so I think it overcalls stresses. So you get stress reactions in the bone and when you see that on the SPECT-CT, you're like, oh my God, that's bad. Whereas in the MAR MRI, it's a little bit more anatomically oriented and you're seeing the T2 images, you're seeing that edema and there's a certain pattern to it. And we know how to read MRIs, we do it all the time. We know when something looks like AVN, it's just hot as heck. And then we have those cases where it's a stress fracture and it's just a little zone. And sometimes it's just like this little wispy thing that we'd say, that's a stress reaction. And I make that call best on the MAR MRI. So I grew up with MAR MRI. I just started doing total ankles 12 years ago. And at that point I talked to Jan Frits and I said, look, I need a better MAR MRI. And he said, let's do it. And I've been so happy with that because I studied my cases that were normal with no symptoms. And then we saw what was normal, the little edema, a little stress reaction, what happens in the soft tissues, what happens anteriorly. So I could really see the problems in a very anatomic fashion. Whereas with the SPECT-CT, it kind of, you get the CAT scan, which is good. And then you get the hotspot, which I think is still non-specific like with other imaging technologies. I mean, if you have an anatomic based one, it's better. And I think just superimposing the more dynamic contrast or tracer elements, I think it gets a little bit too vague. There's another follow-up question from the audience on that. Any concern about timing, about when to obtain a SPECT-CT? So is it better at six months versus two years or vice versa? I think in general, it would be interesting to hear what all my buddies here agree on here because I think we would all say that we expect certain pains post-op. Like at three months, patients will have some medial pain and it could look like it's a medial impingement. It could look like stress reaction of the medial malleolus. It could look like even a stress fracture. And then if it's not too bad and the X-rays look good, we're gonna say, let's keep going, let's watch it. I mean, if the person is floridly tender on the spot and the X-rays don't give us guidance, yeah, then I think I get the MARMRI. But most of the time, I'm getting SPECT-CT or MARMRI, more advanced imaging at six months or maybe even a year because I'm seeing a trend in the patient healing and those zones of pain getting better and better. And so medial pain doesn't alarm me at three months. At six months, most people have medial pain. I'd say it's like maybe 10% of the whole population and those are more concerning. But by a year, that 10% of patients now got dropped down to like 5% or something. And usually it's more clearly mechanical like impingement or it's like a stress reaction in the medial malleolus. So again, kick it down the road if you're seeing progressive improvement of the patient, less tenderness and no weird stuff on X-rays. Hans-Jan, I know you're a big proponent of SPECT-CT. Do you have anything to add to that discussion? Well, I think that SPECT-CT is a tool just like everything else. And so you use it in the context of all your other studies to try to best figure out what's wrong. I don't see a lot of utility in SPECT-CT in less than a year. Even at one year, you're gonna see some activity that may not correlate with symptoms to a point. A lot of times you're looking for asymmetry in activity or you're looking to confirm your suspicion. So the most common scenario is I think someone has gutter impingement but I wanna make sure I'm not overly optimistic and wanna see if there's activity throughout the entire talus. So if I get a SPECT-CT and I see activity in the medial gutter or the medial portion of the talus but then centrally and laterally it looks okay, then I'm reassured that it is gutter impingement. I feel better about going in and debriding the gutter because intraoperatively assessing stability of the implants is a little bit ridiculous, right? I mean, you're kind of pushing on the implant but that's not a very accurate way to really know if something is stable. So I'll use it in that context. I think the farther out, certainly the better. And Liz, I think you should publish your study on the natural history of SPECT-CT and then everybody will have more information. Yes, so very topical. I am actually doing a study that is on the verge of coming out but basically we showed that over the first two years after ankle replacement, activity around the implant remains high. It's going down during that time. So the further out you get, the better, but you can see a lot of activity around the implant even up to two years, both on the tibial and talar sides. I would say that's less dramatic with the MARMRI. I mean, we see some little edema here and there, but at six months, it's not that much. So it's not as noisy and it's more, again, anatomically based. So I think MARMRI at six months may be valuable. Certainly at a year, of course, your healing is done. So it's going to be better still. And I do agree with you. I find MARMRI really helpful. And that's usually kind of the first thing I go to. I go to that before SPECT-CT, mostly because, well, in part, because it's very hard for me to access SPECT-CT, but I do think it's very helpful also. A question for Carl from the audience. Do you place the prophylactic K-wire or screw prior to bone removal? I try to. I mean, it really depends on the system and the case, but when I feel like I'm putting the medial luteus at risk, I stop and put it in if I haven't done it already. Good. And Beth, I've got a bunch of questions for you, but I thought your talk on robotics was super cool. What's really interesting to me is that, you know, when we do total ankles, even if you're using custom guides, they're going off of a preoperative CT scan, but soft tissue tensioning is really not taken into account. So it looks like with the system that you're showing, you're using that, but also you can adjust it in real time, looking at soft tissue tensioning in the OR to adjust your plan. Can you talk a little more about that and how that helps you change or adjust your plan intraoperatively? Yeah, so a lot of the surgery is just making those intraoperative decisions and adjustments. So, and everybody has different thresholds with what they will go to. So for instance, if I'm balancing the knee and I see that there's a seven millimeter gap, you know, my medial side is tighter than my lateral side by seven millimeters or more, I'm not gonna be able to catch up to that with just adjustments of adding varus and valgus into the femur or the tibia. I would have to do something very extreme, like a pure kinematic alignment and leave my knee at seven degrees of overall valgus, which I don't necessarily feel comfortable doing that. Some people might. So at that point, I would release a little bit of the MCL, you know, do a little bit of releasing either MCL or LCL, depending on varus valgus to catch up to that. And then I can rebalance with the robot. So I think just the level of precision that we get is higher because it's accurately measured to within two millimeters. And I think there's probably a ton of potential. I'm clearly not a foot and ankle surgeon, but just seeing how you guys do the surgery and the balancing that you're going for and also the precision that you're going for, I think there's a ton of promise in that area to use intraoperative balancing. So I think more to come. I think still, like I was in the lab yesterday putting a raise in and doing stuff with the company. And I'm thinking to myself, like I bet 10 years from now, we're gonna look back and think that this is so archaic that we had to put pins in to get a raise in to see these things. I think it'll all be even more digital then, but I think there's a lot of potential. Yeah, so super cool. So I guess you all, like you cut your MCL, you're doing all that soft tissue balancing before you make any cuts. And you also have to adjust your cuts. With mild deformities, if it's like under 10 degree varus knee, which is the most common type of knee replacement now, I won't even do much of a release at all. I will just add in two to three degrees of varus on my tibia, and that's basically doing the MCL release for me. And so there's some data, especially from like Vidorchik and others that shows that the less MCL releasing we do, the less LCL releasing we do, the faster the recovery. So if we're able to basically do the releasing just by adding in a little bit of deformity back into the leg, it probably leads to a little bit friendlier of a surgery. Well, you're obviously way more advanced than we are. I don't know. These are all things that I think about a lot when I'm operating, but we don't really have any answers yet. Konstantin, you've got your hand up. Yeah, I have a question for Beth. All right, Beth. So let's say you have a patient and you want to assess for that particular patient how well your implant has healed or grown in, right? And it might be different for cemented or uncemented patients. What's the best imaging modality as far as we know now? So is it x-rays? Is it a CAT scan, lucencies? Is it an MRI and fibrous tissue at that interface? What's the best way to assess percentage of healing of your prosthesis to the surrounding bone? That's such a loaded question. I don't think we have. I think there's, you know, asking on different people, they would give different answers. A lot of joint surgeons will say that they go off of the CT or they go off of the CT scan. They go off of just the x-ray. And then there's some surgeons that really put a lot of stock on a bone scan. I actually think, I don't find bone scans that helpful other than like, you know, the ultimate decider if you're really on the fence. At HSS, we have the benefit of having Maverick and pretty good sequencing in our MRIs. And that's been helpful. But I think even seeing like a fibrous interface in a cemented implant, it's not 100% accurate. And we had the recent unfortunate experience at HSS of we've put in 15,000 Xactec total knees that had a really horrible packaging issue, a lot of osteolysis, and a lot of actually debonding of the femoral component. So it was a cemented femoral component. We put on, looked good on x-ray, but didn't feel right. And when you take it back to the OR, you'd tap it off and you would just be left with a pure cement mantle with no bonding of the cement to the implant. And that's incredibly difficult to tell on imaging. And a lot of those MRIs, don't tell my radiology department, but a lot of those MRIs were read as not loose, but intraoperatively they were loose. So I don't think there is a perfect modality yet. Beth, do you think those were loose when you looked at them? When I look back in hindsight, you mean? Yeah. I don't think so. I think the only thing was they have joined effusions. So you knew something wasn't right, but at the interface, they looked okay. Just probably because it was almost like a suction interface between the cement and the implant. And so it probably wasn't a lot of actual movement, but if you take your bone tamp on it, they would just pop right off. Yeah. Yeah. So on the cemented versus cementless topic, you mentioned that there's increasing popularity of presbyt implants. You sort of looked at different groups. One of your data slides showed this, but have you seen a higher rate of mechanical loosening in one of the other group? Yeah. So the one that's failing a lot is the over 65 year old female. Not a lot. It's still low, and it's mostly related to actual fractures. It's not necessarily loosening. So my practice is still about 70% of women over 70. So I personally don't use a lot of cementless implants. I'm more like 20 to 30% compared to the national average probably getting close to 50%. So I'm still pretty conservative because I am following those registry numbers about that. And I think that's the other tough thing. And you guys, I'm curious to see the ankle experience of like what's the breakdown, but when somebody comes in with a little bit of pain six months after a cementless knee, it's tricky. You never really know if it's, is it that they're not ingrown or is it just an unhappy knee for other reasons? So that's always a tricky workup for us. Yeah, we've got very similar questions. I mean, most of the total ankle implants we have now are pretty low profile. So they're prone to loosening. So there's like a three to 4% rate of mechanical loosening or failure from loosening. But then, you know, pretty much everybody is using cementless now for total ankles. And I think the idea is if the bone grows onto it, it's going to be good for a very, very long time. Whereas with cemented, I think it's a little more unclear. Got it. Yeah. If you want to see our cementing techniques, I'd recommend not going in our ORs. Probably compared to what you're used to doing. Are there still, so the breakdown, it's well over 50% of total ankles are cementless. Yeah. I think like 95% or something, I don't know. Interesting, we're looking a lot more, right now our uni or uni-compartmental knee replacements are in the majority of the designs are cemented designs. There's one company, Zimmer, that has the Oxford that's cementless. It's really popular in Europe, starting getting popular in US. And it looks really similar to your, the one implant that you showed, Carl, I think is a talus, the tibial component, excuse me, the tibial component of a cementless implant with two pegs looks really similar to how we would put in a potential uni cementless design. And I'm always worried about that just being such a small surface area, but three to 4% is not terrible. Do you think there's any design features that are coming out that are going to help that go down? Well, there's the big stemmed implant that I'm sure you saw, and you really don't get loosening with that. It's like a 1% rate or less. So yeah, I think there's more of a trend towards stemmed implants because there's a lower rate of loosening, but again, the stemmed implants carry their own problems too. Right? Do the pegs have higher, if it's just a peg and not two pegs and not a stem, is it higher fracture incidence? I would say there's probably a higher fracture incidence with the stemmed implant, but yeah, I don't know that anybody specifically looked at that. Constantine, you've got your hand up. Yeah, just a comment, and Beth, please correct me if I'm wrong, but my understanding is, cement is really particularly challenged in shear, much less so in compression, and there's a lot of shear forces in the ankle. And so historically when implants were fully cemented, they really did not do well, and which was what drove a lot of us to go uncemented, certainly before my time and currently. And there may be a role for a hybrid fixation model where there's some cement for initial stability while the bone can grow to the remainder of the implant, and that's not very well appreciated, studied, certainly complex question, right? I mean, what does some cement mean? You know, where do you put it? How much do you use? But that's a question, a fundamental question of cemented versus uncemented that we really have not done in a prospective, clear way with our current generation of implants. Lou, you wanna comment? Yeah, with the TM ankle, we have tantalum versus titanium. It's a low profile ankle, and we teach to cement the rails, but I think Steve Herbst and Charlie Saltzman found a lower incidence of problems with cementing right over the rails with liquid cement after the implants in, and we did some biomechanics on it. It did show less micro motion early on, and that may have helped them to get in growth. I didn't have a problem with that. In my series, we had 130, which we presented in Europe, but 130 with no metal or plastic failures, and only 2% were cemented, and it was five to 12 years, no metal or plastic failures, and most of them, again, not cemented. So the tantalum, I think, is pretty good. That's maybe a better surface, and I think if you're gonna cement, having a cement technique where you can kind of squirt in after you implant in may be better than covering your whole implant with cement. Yeah, even in the knee world, the hybrid fixation's really taken off in revision settings, so we're using tantalum or titanium, which is an alternative porous coating, 3D-printed metal, but we're using metaphyseal cones and sleeves that are uncemented that will highly porous, really grows in like gangbusters, and then just cementing at the joint interface or cementing if we're doing a long stem or shorter stem below it, but that hybrid fixation model, and we call it zonal fixation, so getting the uncemented fixation and in-growth in zone two or the metaphysis, and then fixation both at the diaphysis and the epiphys level with the cement has worked out very well in much lower revision rates of our revision cases, but it hasn't taken off in primaries yet. But again, to Konstantin's point, we don't have the same shear forces, right? So our aseptic loosening with cemented implants, like our uncemented implants in total knees is really an industry-created problem, and it's industry-driven. Like we are not seeing a lot of aseptic loosening from our primary cemented implants. It's just, it's faster and it's fun is really the biggest reason to do it. Thank you all for an amazing discussion. I feel like I really learned a lot from all of your talks and also the discussion we had after. We're gonna be moving on to the next session now, so I'll hand it back to Chris. Hey, thank you all. I learned a ton, and Beth in particular, thank you for joining. I really hope, you know, maybe this was a, hopefully some other webinars can happen where we have so much like crosstalk across subspecialties here because this was a really stimulating conversation I think for everybody here. So thank you for joining and sharing your time and expertise. Thanks again. Anyways, back to Jacob to go on to non-unions and bone loss. Yeah, we're going to keep the disaster train rolling and we're going to kick it off with Dr. Amanda Fantry who's in Connecticut and she is going to be talking to us about Taylor AVN. Okay, hi everyone. So I am talking about Taylor AVN and since this is in the malunions and bone loss section, I also included some tail or neck malunions as well. So there's nothing like a true level of jet lagged mania to get through like, you know, 80 slides in 15 minutes. So we're going to do that. So I don't have any disclosures, but per usual, I'm always open to new disclosures or any disclosures. Just a quick reminder, the talus has nothing that attaches to it. It's mostly cartilage and the blood supply sucks. When you talk about the blood supply, you can easily see how particularly trauma can lead to AVN of the talus, but you have, you know, three blood supplies to the talus and yet still we get AVN. It's really some sort of fault of human anatomy. So in talking about malunion, this is a tail or neck fracture I fixed, I don't know, a couple months ago. And tail or neck fractures are one of those things that you look at and then you fix them and then you look at them and then every time they come to their office, you look at them some more and you just hope that the tail or head or the tail or body isn't dying. But tail or neck fractures are fairly uncommon and can be missed and that's, you know, if they're part of a polytrauma and that's part of the problem. And the complications of tail or neck fractures, you can see here that there's increasing sclerosis over the body and this patient is developing AVN and that risk can be related to your Hawkins classification, which we'll get to in a little bit, and can involve either your ankle or your subtalar joints and other complications, the obvious things, infection, malunion or nonunion, and this little part of the talk is predominantly about malunion. And when we talk about malunion, we predominantly talk about this classification, the Zwip and Ramelt, where you talk about malunion versus nonunion and then whether or not they have AVN. And when we look at patients who present with tail or neck malunion, they do typically present in varus and we classically are taught that these are varus deformities where you can have involvement of your ankle or your hind foot and they can be stiff or flexible, but they are worse with weight bearing and you can get lateral column overload. The risks are predominantly whether or not this was treated non-operatively at all, or then your kind of standard operative mishaps. You went only medially, you compressed across a shortened medial comminuted surface and then shortened your talus, put it into varus and developed a malunion. Interestingly, last year at the AOFAS meeting, they presented 10 patients, six males and females, where they looked at the tail or neck malunions, predominantly of type 1 and type 3, so not significant AVN or claps, but malunions. And interestingly, while a majority of them are in varus, you can also have valgus malunions. And in the sagittal plane, you can have malunions where your dorsi flexed, plantar flexed, or in neutral. And so you don't want to think that all malunions are simply varus malunions. They're not. And so weight bearing CT, if you have access to one, I don't, but I like to pretend that I do, because if you can get one, it can be helpful here at telling you exactly what your deformity is. And when you want to take care of a malunion, your goal here, if possible, is to correct your malunion and limit your arthrodesis. However, you really need to take a significant intraoperative look at viable cartilage and the joints involved and determine whether or not they are salvageable. If you are looking predominantly, again, at malunions without significant AVN, then you want to determine if you can preserve your joints, and that requires reliable patients, adequate bone stock, and good articular cartilage. And so there's certainly a discussion to be had with the patients about evaluating them intraoperatively and whether or not they need an arthrodesis of one joint or more joints, or whether or not you can simply osteotomize their previous malunion, add bone graft, and get that to heal. Now, nearly like 20 years ago, they looked at this. They followed patients for four years. They did an anteromedial and lateral approach. They osteotomized all of these through the fracture plane, added bone graft, and did any concomitant procedures. And this patient was six months out when they went into this procedure. This is from the paper. This kid was like 21, and they fixed it. And interestingly, they had like really good results. Increased AOFS scores. People were happy that they didn't go on to fusions. This is the same thing from a more recent paper. This patient was 10 months out. You look at this CT, or I look at this CT, and I think fusion is going to be my option, or some type of arthrodesis procedure, or arthroplasty, but certainly not salvage. And there's a fair amount of case reports, level four data about osteotomizing through your malunion, harvesting crest, a structural graft. You can see here, they do a medial malleolar osteotomy, wedge open the nonunion site, graft it. And while you can see some abnormality about the tibial-talar surface, it certainly went on to heal. But your goal is to improve your alignment, as we always say, get a plantigrade foot, figure out what can be spared versus what needs to be fused. So this is cases from one of my co-fellows, and she inherited this patient who came in with this previous talar neck fracture with a nonunion or malunion, with an attempted subtalar fusion as well. They were overall in pain and had this kind of like weird anterior hardware. She tried to revise it, and you can see that there's a fair amount of sclerosis in the talar body, and this was likely going on to ADN. She kept them non-weight bearing for 12 weeks. And then when they went to weight bear, it all collapsed. And so one of our options that we'll talk about a little bit more is arthroplasty or total talus replacement in here with a revision subtalar component. For the AVN portion, which I think was what my talk was supposed to actually be about, a majority of this is from talar neck fractures, 75%, and then you consider your non-traumatic etiologies, all of the kind of things that we think about whenever we think about AVN. When you think about AVN of other bones or joints and you think about like femoral head AVN, that's a pretty straightforward problem. And I don't know if our arthroplasty colleague has left, but you know, AVN of the hip, you're like, okay, I get a total hip, right? They're putting total hips in people who are 16 who had sickle cell or got chemotherapy, but that's a much harder proposition for foot and ankle when you're like, oh, we'll just give a 16-year-old a total talus, right? It's not a great option. This paper is now about 10 years old, but I think it's pretty helpful at thinking about what types of talar neck fractures and what classification, modifying the Hawkins classification to 2A and 2B with or without subtalar dislocations can contribute to AVN or hind foot arthritis or ankle arthritis. And I think that this is much more helpful to me than looking at the initial Hawkins classification where it's like 25%, 50%, 75%, 100%, right? No, there's no 100% of talar neck fractures that are getting AVN. And so I often will reference this table. So I included it here and we're talking about your if I could scale. Again, patients will often present with anterior ankle pain or hind foot pain. They can be in varus. They frequently had previous trauma and you want to do a good physical exam. When you talk about what you're managing this with and you're looking at data, I think Dr. Kayaki's talk is really helpful when he's like, yeah, I just show you some cases and this is way better than data because there's data like this, right? It's like this paper is now 10 years old. Arthroplasty wasn't really around that much of the time. There's only one paper at the bottom that you can see that included arthroplasty, but it's predominantly level four evidence with not that many patients. What they used as an outcome score, how they treated them, they all varied. So we're just comparing like, I don't know, apples to some other bizarre fruit and it's not that reliable. And so, right, what they use for outcome scores are different. So this is the kind of data we have, right? Dr. Lauren Gainey actually gave me this algorithm, which I thought was really helpful, that when you want to talk about AVN of the talus and management of AVN, you really want to look at breaking this down into kind of simple, do they have collapse of their talus or not? And then once they have collapse, what joints are involved, right? Does it involve more than your ankle? Is it just your talus? Is your tibia involved? And then what are your options? So a couple of cases. So here's a 60 year old female who came to my office now, I don't know, a while ago, but she has eight months of pain. She has a fair amount of swelling. She can't walk. She had conservative treatment of which there is some data that long standing non-weight bearing can be beneficial for AVN, but it's like nine to 12 months of non-weight bearing. And since this is a surgery talk, I didn't really talk about that. So you get her MRI. She has a joint effusion. She has AVN, but without any obvious evidence of collapse, predominantly more medial than lateral. And when you look at this, you think, okay, I can do plus minus an arthroscopy with retrograde drilling. And when this paper looked at core decompression, and again, it's not a great study. They looked at four studies of which predominantly or if I count one and two, but some are level three, they're all level four case series. And when you do this, you want to use some kind of trocar, a drill, and you obviously want to remove some type of core bone. Some people are bone grafting this, some people are not. And predominantly these patients did well and they had a low rate of conversion to fusion. So for your patients without collapse, it's certainly a much easier pathway to consider than getting into arthrodesis and arthroplasty and can be successful in patients without tailor collapse. There is research on vascularized bone graft that you can take from the cuboid, the medial cuneiform, the lateral cuneiform, or the supracondylar distal femur. I don't have any experience with that. So I'm not going to talk about it, but if I'm sure that there are people doing this. When you get into your fusion options, and I'm going to leave out large bony defects because I know Dr. Weatherford is talking about that shortly, but you can talk about fusion of essentially a myriad of your ankle, hindfoot, pan-tailor, and then plus or minus arthroplasty with or without fusion. When you talk about bulk allografts, you can talk about thermal head or tailor allografts, but they have a high complication rate, right? So there's a high risk of non-union, upwards of 50% in some studies, and it's just hard to tell patients that they have a 50-50 risk of having a successful surgery with a prolonged period of non-weight-bearing and recovery and adjacent joint arthritis, particularly with fusions. My second case is a 34-year-old female. She's had a year and a half of left ankle pain. She previously had ORF of the tails and medial malleolus. She was kept non-weight-bearing for three months. She is a CNA, and she also is a smoker. She has some ankle motion remaining. She has full hindfoot motion and no sub-tailor pain. This was not my case, but you can see that she's developing sclerosis of her tailored body, kind of abnormal morphology of her tibiotailor joint. She does have this large, acidic piece next to her medial malleolus, but we'll ignore that. She's developed collapse of her head and involvement of both her tibia and her talus. Without sub-tailor involvement, then you start talking about what your options are, whether you're considering arthrodesis or arthroplasty. For her, she's 60. She's a smoker. She underwent an ankle fusion and did quite well. For the third case, patient's 29, had a very remote history of childhood ankle fracture and revision. She has caboverous alignment, and she has involvement and pain over her ankle and her sub-tailor joint. Again, now we're talking about abnormal tibiotailor morphology, obvious collapse of her talus, broken hardware in her talus, and significant sclerosis of her talus. She has a malunion or nonunion of her tailored neck. And when we move down our algorithm, then we're talking about TTC or a total talus with an ankle replacement and or a fusion. She's 29. That's probably not a great option for her. So here's some intraoperative pictures. I think this case might have come from Liz Cody, but maybe that's a later one. But removal of her dead talus, in which case you're stuck with this large bony defect, allograft or femoral head allograft placed in there, and then a large fusion construct. This is a huge risky surgery. You try and add all the biologics you can, and Dr. Barreto will talk about that, to try and get these big bony defects to heal across. And lastly, and kind of more becoming more popular, are joint and motion sparing options where you can look at total ankle arthroplasty with or without a total talus and prosthesis or a total talus alone. There are risks to these, right? And that's kind of, I think there's a couple problems, right? One is cost and access for surgeons to get a total talus and use it at their institution. And the other is that if you do a total talus, you don't have a ton of great salvage options. We're still trying to figure out what your next steps are. If you put this into any degree of varus, you have a risk of a medial malleolus fracture, much like a total ankle. And there's not long-term data. There's currently short-term and medium-term data up to about 10 years. And so for another case, 62-year-old female, previous ORF of talus with a subtalar fusion, but has a BMI of 52, you can see that her talus is collapsing. Her hardware is now penetrating her tibiotalar joint. And you can see that there's kind of fragmentation of her talus. And overall, this doesn't look like a great joint. Her fusion has a nonunion. And so overall, a fairly big problem here. So again, now we're talking about a person who has a BMI of 52. And what are your options? Then I'll just skip to the end of the story. But here, a total talus with a nail was selected in order to, because that bone was non-viable, and thought that this would be a better option than a big allograft for getting an actual fusion. And when you look at a recent paper from FAI, they looked at, am I done? Do I have one minute? Okay, last one. So when you look at a TTC versus talar prosthesis over a seven-year period, they did a level three study, which is about the best evidence we have of this so far. It's kind of standard, took down the fibula, mixed it with allograft versus a talus arthroplasty. And what you can see is that obviously there's no nonunion across a talar body prosthesis, but adjacent joint arthritis was actually very minimal. There was no evidence of loosening or problems. And the conclusions are that you have a much higher survivability with a prosthesis than you do with a TTC, with lower pain scores, lower complication, and a faster recovery. And so this remains a difficult problem. There's no great answers for this. Try a core decompression when you can, and then everything after that is kind of up to you. And this is my recent camel ride from last week. Awesome. Thanks, Amanda. Okay. Now we're going to go to Todd Irwin from Charlotte, who's going to talk to us about doing primary fusions for bad trauma. Great. Thank you, Jacob. Appreciate the opportunity to talk today and learn from all of my co-presenters. It's been a great course so far. So we're going to talk about primary fusion It's been a great course so far. So we're going to talk about primary fusion for ankle and high foot trauma. Let's see if I can, there we go. Here are my disclosures. Nothing is irrelevant to this talk. So this is just kind of a first case of sort of woulda, coulda, shoulda. This is when I first moved back to Charlotte about seven years ago. I was a couple of weeks into my kind of new practice, and this 29-year-old guy fell from 10 feet two days prior, showed up in clinic, two-pack-a-day smoker, mild TBI, wasn't open, but was trying to be. And so we did what we were supposed to do and what they should have done two days earlier and put him into an X-Fix. And then here's his CT scan. And I'll just kind of play them both at the same time. So not the worst Pilon you've ever seen, but significant articular involvement, certainly bad. We know he's going to do poorly. So we did discuss ORIF versus primary fusion. We proceeded with ORIF as was kind of his wish. And unfortunately we did a front back ORIF, he developed an infection, needed an IED, then a free flap by plastic. So at six weeks post-op, this is after his free flap, and we had restored his bone stock, looked okay, but certainly not the end of the story. So he did kind of have some insurance issues, disappeared for a while, but it was on suppressive oral antibiotics. At 18 months, I finally got him back to take out his hardware, and this is what he looked like. So again, he did sort of disappear for a while. Unfortunately, five years later, which was literally about two or three weeks ago, a month ago, he called back asking about fusions and how long he would have to go without cigarettes and beer if we did that. So in one respect, you could make the argument that we bought him five years. In the other respect, we could say, well, we just would have fused him primarily. I wouldn't have to be answering these ridiculous tasks, but that is me venting. So when I thought about this talk, I thought, you know, we need to talk about different anatomic considerations, in particular, what type of fractures and then which joints to include. Clearly with ankles and talus fractures, you're going to talk about either an ankle fusion or a TTC fusion. And with the calcaneus fractures and talus fractures, either a subtalar fusion or a TTC. I didn't really include talo-invicular joint or CC joint as those, I think, usually don't really require primary fusion. So we're going to focus on these. I think the other considerations which are super important are these. So severity is clearly one of the main considerations. Comorbidities, super important, in particular medical comorbidities, but also age, smoking status, et cetera. And then how chronic is it? Is it acute, subacute, late? And what I kind of learned as I was looking through these, a lot of this, there's a lot of overlap between comorbidity and chronicity as people with comorbidities end up being sometimes these more sort of subacute or late presentations. So we're going to start with the easy one with calcaneus fractures. You know, we all know about the Sanders classifications. You know, my training back in the early mid 2000s was pretty much ORIF type twos and threes only do primary fusions on fours. But I would argue that, you know, there's sort of variants of all of these on the left, clearly kind of a type four in the middle. This is really a type two, but it's more fracture dislocation. And then on the right you know, maybe it's a two at the posterior facet, but it's a three a little bit more anteriorly. So I think it's not always clear. This is a study looking at type fours showing actually no statistical difference in ORIF versus primary subtalar fusion. However, we know the primary fusion patients heal pretty quickly. It prevents a late secondary fusion. More recently, some of my partners here in Charlotte published a study looking at primary arthrodesis for calc fractures. And about 40% of these were type threes had very good union rates and reasonable patient satisfaction scores. So this is kind of where I'm at at this point is I am pretty much fusing threes and fours and doing ORIF and type twos unless there are other considerations. So just a couple of examples is a 51 year old female, a motor vehicle accident. She didn't have insurance, which we don't like to make decisions really based on that. However, when you think about if they're going to need more surgery in the future and what's going to sort of get them back to their life, maybe you should consider a primary fusion. I think this is one of those kind of twos versus threes depending on where you look at the injury. So we proceeded with a primary subtalar fusion for her. I do like to stress it's still an ORIF in my opinion. You don't have to necessarily plate it if you don't want, but I think you have to restore the morphology of the calcaneus at the same time as doing your primary fusion. Another quick example, 42 year old male. He was blind. He had a learning disability. There was a lot of alcohol use. The injury was maybe three weeks ago, kind of unclear by history. So he fits into that comorbidity category, but also a bit of the chronicity and the subacute nature. So again, ORIF with primary subtalar fusion. So I don't think any of this is groundbreaking. I think a lot of us do primary subtalar fusions, but it's certainly a good option. For talus fractures, there's not really much data out there that I could find. This is a trail map at Canyons in Utah. And I've always thought this was pretty interesting that one of their runs is called the talus garden. So I'm certainly not brave enough to venture there, but some of you maybe are. We know the classification of talus neck fractures, which Amanda did a nice job talking about. I agree. I like that kind of 2A and 2B type discussion on this. And so there's a couple of studies. We talk about this a lot. You know, AVN is, as we just covered, but really the most common, which we all know from our OITE is post-traumatic arthritis. And in particular post-traumatic arthritis subtalar joint. So this was a systematic review where the mean rate of subtalar DJD was 49%, but then in the studies that had greater than two year followup, it increased to 81%. So the question is, should we be fusing more of these subtalar joints primarily? I think, you know, maybe sometimes, but here's a couple of examples of maybe when that is. So this was a 61 year old female. She fell through some fluorine four weeks earlier. So she is diabetic. She had an A1C of 8.1. Initially placed in an air cast. We've all seen this happen, you know, many times really doesn't look that bad, but then she comes in four weeks later, saw one of our PAs. Clearly she's developing a various deformity to her left ankle. This is the lateral view. And then when you compare it to the opposite view, there's certainly a lot going on. So we get our CT scan. Here's the CT again, showing a tailored neck and body fracture with calcaneal involvement as well. You know, with her diabetes, is neuropathy playing a role here? You know, possibly she's still only a month out. But, you know, this is a, a certainly a bad actor. So again, I think she fits into the category of comorbidity and, and she's a little bit subcute as well. So I thought this was very clever. I said, well, I'm going to go fix that, that tailored neck fracture with a PDA screw. It's relatively non-displaced. I'm going to fix the anterior process fracture and then, and then do a primary fusion. I definitely tried to get her out of Varus. I don't think it did a great job of that. I think this was reasonable, but not great. So whether or not that played a role in this, I think, I think it's one of the important things is try to get them out of Varus. So here she is at 12 weeks post-op after her primary subtalar fusion and clearly not looking great. Not terrible, but not really sure which way this is going to go yet. So we followed her along. At eight months, we finally get a CT scan and you can see now this just looks bad. She's got a subtalar non-union. She's got AVN of her talus. She's got a fracture through the, a new fracture through the posterior talus. And so in this case, we then had to convert her to a TTC fusion. So this is six months out. She's healing relatively well. Her clinical alignment is better. I think she's neutral and not really in Varus anymore. Here's another example of a talus that needed to be treated at the primary fusion. This was an 85 year old female, MVC. No, no significant past medical history other than a little lumbar radiculopathy. Initial x-rays, just a terrible Weber B or Weber A ankle fracture. Just kidding. But she was seen by one of our orthopedic, general orthopedic surgeons out in the community. Unfortunately at two weeks, they got x-rays, but didn't notice the talus fracture in the posterior body. And then three and a half months, this is what, this is what it looked like. So this is when she gets sent over here to us and her CT scan at four months. Again, now we've got significant DJD, you know, Taylor body fracture. There's some posterior translation of the talus. So at this point, again, she fits into this comorbidity, a bit more of the age category, as well as a bit of chronicity. So at five months out, she is healing well from her TTC fusion, which I felt was the best approach for her. And at seven months out, her CT scan is showing good fusion. But what about Pilon fractures? I think this is kind of the, one of the main things to talk about. This is, you know, maybe more controversial than any. We know Pilon fractures do terrible. They do worse than people with acute MIs and diabetes and people, people with AIDS. But do primary fusions work? There's a handful of studies out there and not a lot of great science. This is one out of Oregon with Doug Beeman and Rich Gelman looking at just 12 Pilon's treated with anterior ankle fusion plates and possibly a ring fixator. Good, good results in terms of non-union malunion and reasonable outcome scores. I think this is kind of the main patient to talk about in terms of Pilon's. This is a 48 year old male, fell off a ladder while trimming a tree. You know, his initial AP and mortis don't look terrible, but then you look at the lateral and you see this significant anterior impaction which we know by other studies portends a relatively poor outcome. If you look at the sagittal CT scan, you can see not only is it anterior plafond involvement, it's also really almost the entire plafond is impacted. So we just know this guy's going to do, do terrible. So this really fits into that severity category. And so we proceeded with the primary tibial-talar arthrodesis on him. He was 10 months out, did not have to fix his fibula. It actually healed fine without having to make another incision there. I think the big debate here with this type of person is, and then in this day and age, do we do primary fusions on this patient or do we preserve bone stock, do an ORF and leave total ankle as an option? I think it's a very good debate to have. So who needs these is really kind of the question. Another quick example, this is a 75 year old guy who had had a few different injuries over a few months. No, no neuropathy, his SEMS-Weinstein was actually normal. But you look at this and you're like, how can this person not be neuropathic? I think the question here isn't really, do they need a fusion or not? It's, do you do an ankle fusion or do you do a TTC fusion? So in this case, I proceeded with just a primary tibial-talar fusion. I think you could argue it either way. I think with his normal SEMS-Weinstein, that was one of the things that drove me to just do a primary tibial-talar fusion. And at eight months he was, he was doing well. Again, similar idea. He had this medial malleolus fracture, which you can kind of just ignore, do the fusion and things heal up. What about the literature? This is a comparison of primary fusions to ORF out of a Pittsburgh group. They've actually had a few studies on primary fusions here. They kind of reported comparable functional outcomes. The fusion had a little bit increased pain and decreased role limits, but the ORFs had significant post-traumatic DJD. And then the next question is what about doing a tibial-talar nail or an unprepped nail for ankle fractures? And so I think this is a concept that a lot of our trauma doctors also do. This really looked at these types of patients and the elderly and about an 81.5% return to similar preop mobility status. So here's an example. I think this is the best example of this. This is not quite an elderly patient, but she had advanced. She was 54. She had advanced COPD. She was bipolar, CHF, chronic opioid use with a BMI of 40. Again, not the worst ankle fracture you've ever seen. I would call this a posterior pilon variant, but we fix these all the time. But in this patient, I think it's very reasonable to consider a primary fusion. Again, she fits into this comorbidity category in terms of medical comorbidity. So we proceeded with primary TTC fusion in her. I did a sort of mini-arthrotomy approach to the ankle and then a separate sinus tarsae approach. I think, again, one of the other debates with the trauma doctors is do you do just unprepped nails or are you going to prep the joints and do a primary fusion? Feel pretty strongly if you're going to be doing this, you might as well fuse it and prep it and try to get a good fusion. You can certainly do this with an MIS approach and BIRS. For this, I typically do more just kind of an open, mini-open type approach, but doing BIRS is reasonable. So this is her at three months. She did get a little bit lost to follow up with all of her hospitalizations, but at 18 months, the lateral view shows a good fusion and early weight bearing. So this is the last study. Again, this is sort of similar looking at fragility fractures in the elderly, but comparing TTC nails to ORIFs. This is out of Greece. And again, they showed reoperation rate much higher in ORIF patients. No difference in returning to pre-injury mobility status. But again, I would argue they didn't prep the joints. Their ORIF patients had sort of non-modern fixation. They didn't really talk about did they fix this in dysmosis. And then we've all seen this kind of patient who had sort of an unprepped nail who then comes in a couple of years later, nails removed, bad arthritis. So I think you can avoid this by doing primary fusions in the right patients. So I think, again, I think it's a viable option, a good option in the right patient. I think you consider the severity, the chronicity, the comorbidities. These are obviously life-changing injuries, all of these. And just if you take the patient as a whole, maybe a single stage primary fusion is preferable to having them go through multiple surgeries in the future. The last thing I would tell you is beware of neuropathy. I think this really drives me in terms of whether I'm going to do just a primary fusion or a TTC or maybe a fusion versus an ORIF. So it's certainly a lot of subclinical neuropathy out there. So thank you very much in particular. Thank you, Jacob, for the invitation. Awesome. Thanks, Todd. Awesome. Great talk. Okay, now we're going to go to Brian Weatherford, who's in Chicago, who's going to be talking to us about large tibial and tailor bone defects. Thanks, Brian. All right. Thank you. And thanks, everyone, for having me here. Really enjoying listening to everyone and learning for everyone. So I think I get the honor of presenting perhaps a completely data-free talk, which is managing these large defects. And there's multiple sources, whether it's failed arthroplasty, post-traumatic, or infection. These are my disclosures. I don't think you're going to see much of this stuff used here, or maybe you will. So objectives. So for me, when I'm looking at these, I kind of have some core basic principles or guidelines that I look at. I definitely think of these as a choose-your-own-adventure, where you could still end up in disaster, depending on if you pick the wrong path. But there's arthroplasty. You can use nails. You can use frames. You can use custom implants. And I think you have to talk with patients with these significant defects. I think you really have to talk to them about the A word, which is amputation. Because before you go down this path of sometimes three or four or five surgeries to salvage their limb, you have to know that they understand what you're dealing with. So my basic principles are you have to understand the problem. And so I do have a background in trauma as well. So there's this thing called preoperative planning that we're really big fans of. So I sometimes even make a list and write out all of the problems and how I'm going to deal with each individual problem with whatever path I choose. Understanding the patient is critical. I think Todd did a great job of bringing that up in his talk. Not just the patient issues they bring, but what does the patient want out of the operation? And also what can they tolerate? Meaning, do you think that they're going to be able to get through six months in an external fixator? Going into that is also what is their support network? Because doing this is usually kind of takes a village. And if someone doesn't have a big social support network, you might want to choose an option that is a single surgery. And then lastly, understanding yourself. What options can you offer? And really, where is your skill set? What are you best at? If you're someone who you're really facile with doing femoral head grafts, you do that. If you're someone who's very comfortable using frames, then you do that. So again, understanding the problem. I like to write a list out sometimes. This is a guy who has an amputation on his other side, actually. He presented. I had taken care of him previously. I'd sent him to Florida. Seemed to be doing okay. And he comes back with this. So he's got an infection, an unhealed attempted ankle, subtalar arthrodesis. He somehow broke his tibia above it. Now he's got a tibial nonunion that possibly also is infected with an open lateral wound. And so you've got to think, if he doesn't want to have bilateral amputations, what can you do? And how can you go about addressing these problems to get him to have a salvage limb with a bone defect he has? The basic principles when thinking about the problem for me are, number one, you have to get rid of infection. If you don't get rid of any infected tissue, you cannot go on to step two. And that includes removing dead tissue, including bone. And then the basics of restoring alignment. The goal for most of these is getting whatever is known as a stable plantigrade foot. So again, patient goals, what do they do? Do they really understand what's required? And I think this is a really long preoperative discussion. This is the so-called clinic buster, where you're spending 45 minutes with them, bringing an example of an external fixator in and showing them, this is what it looks like. This is what you'll be in. I still think sometimes they don't fully understand until they're kind of halfway into it. And again, can they tolerate what is required or do they have the support to tolerate what's required? Again, understanding yourself, what can you provide? I think a lot of this is fusion, reconstruction, which I take to being maybe deformity correction, use of circular external fixators, sometimes even arthroplasty, which is stepping on toes. We won't talk much about that. The resources you have available to you are critical as well. I mean, this is something where managing these large bone defects, they typically come in trauma patients, in patients who have poor soft tissues. And so having support from plastics, vascular, prosthetists, physical therapy, wound care specialists, I think that's really important to really tackle some of these challenging problems. Having mentors to rely on is huge as well, including having them just tell you, don't do this, it's a terrible idea. So I think really leaning on your mentors here to help you figure out these challenging issues. So when you start to look at these patients, I think obviously the history is critical. So what treatments that they have before, try to get previous copies of their x-rays, try to figure out where they started, what surgeries have they had, have they had any infections? Are they still infected? What were they like before their initial injury or incident that led to this issue? And what are their current limitations? So physical exam is absolutely critical for this. Looking at previous incisions, assessing their limb alignment, I think doing for a lot of these people with lower extremity deformities, looking at their thigh foot axis, a lot of them have rotational deformities that are not always appreciated. Seeing how they walk, again, as Todd talked about, looking for any signs of neuropathy or sensory issues that could alter your plan. So imaging, there's no specific imaging for this, but I think the more you get, the better, the more data you have, the better. Weight-bearing x-rays are critical. I get standing alignment views in all of these patients. And this is a patient you're looking at here, which you say, okay, it looks like they have maybe some mild ankle joint arthritis. And you get a limb alignment view and it turns out that they have a leg length discrepancy with a malunited tibia fracture in valgus with a posterior plate on their tibia. And that really alters what you're looking at to treat this patient. So just talking a little bit about previous management, which goes back to Amanda's talk. So two patients with the same problem, both of whom have EVN plus minus infection after a talus fracture. So these are patients that I treated in my practice with femoral head allograft. And I always wonder, is this a solution? Because as Amanda talked about, the chance of healing we think is about 50%, maybe a little bit better in some studies, but is this the best that we can offer people for managing these defects? And the issue is twofold. So the first patient I had actually healed, but I couldn't even get close to adequately restoring their limb length with the use of that femoral head graft. And then the second patient progressed on to a symptomatic non-union requiring further treatment. So I think this is still a reasonable option in certain situations, but not necessarily the only option. All right, so this is my first case. So this is a 48-year-old female. She had a previous failed total ankle arthroplasty. She had two previous infections. I actually have no idea what that screw is doing up there going between the tibia and fibula at the mid-diaphysis. Bad lateral soft tissues and starting off with a five or six centimeter bone defect. So my partner actually took care of the first part of this. So he took out the previous implants, put a giant spacer in to treat the infection and said, here you go. So I said, thank you so much. You can see a positive wound vac sign if you're looking very carefully on the on the AP view there. So she's got a resolving lateral wound, poor soft tissues, big, big bone defect. How do we go about treating this? And again, there's no right answer. This is a choose-your-own-adventure. I think we could all say a femoral head is probably gonna be challenging here. I know some people are doing stacked femoral heads or whatever it is. And I guess if you want a really expensive failure, that's one good way to go. But I think the alternatives would be probably a custom implant, which again is getting into the expense, there's no doubt. Or for me, this is a frame. And again, we can talk about some alternative options, but this is a frame for me. And again, you want to make sure that the patient understands if they're not interested in having an amputation, what is going to be required for that. So this is jumping right into it. So this is for me, there are different ways to do this. You can shorten them first and then lengthen them. I chose in this situation to do a transport. One of the things that was originally in my talk was the Mascalet technique. And so I'm not sure how well applied that is for these defects around the foot and ankle, because you really have to have good vascularity. So Mascalet works great in the femur, OK in the tibia. And then I don't really know if we have great data on it in the foot and ankle, at least not that I'm aware of. But this is something that is kind of a Mascalet technique. So we've got this antibiotic spacer with a wire. And what I'm trying to do is to create a little bit of a membrane to drag that transport segment through. And so then we fast forward here. So this is seven months and two, possibly three surgeries later. I think there might have been a surgery for a bad pin tract infection somewhere in there. And so now we have restored length. We have docked the tibia to the calcaneus. And this is really where the challenge comes for me. So I had some experience with frames in my trauma fellowship. I have definitely done a decent amount of it in practice, but I would not say I'm a classically trained Alizarov person. And so I have a lot of hard I have a very hard time getting these things to heal. I can get them at length. I can get them aligned. But getting them over the hump in terms of getting the heal is always a challenge. So ultimately, I converted this person to internal fixation. So this is something that I do with these cases sometimes is this is actually an upside down tibial nail put in retrograde. You can also do a femoral nail as well. So a retrograde femoral nail sometimes works. And so you can get multiple interlocks. You get them out of the frame earlier because this is usually the point where they're going absolutely insane from having the frame on for seven or eight months. And then I think it helps to kind of accelerate the healing of the regenerate bone. So this is her at three year follow up. So and I would say, you know, obviously looking here, right, so that's not a solid union at the tibial to calcaneal arthrodesis site, although currently asymptomatic. I would say, you know, the fancy term we use in trauma is an implant dependent union, which is just a good way of saying a nonunion that hasn't completely failed. And then unfortunately, she got her knee arthritis on the other side of dress. So now she still has a leg length inequality. But I think overall, she's actually doing exceptionally well. She's functioning, living her life, is able to walk without a brace. So not the worst outcome possible. OK, so problem number two. So this is looking at another way to address this. Again, there's no right or wrong way. But so this is someone who's failed a total ankle arthroplasty times two. The second stage involved some kind of a trabecular metal augment under their dead, subsided talus, which just wasn't going to work for them. So they come in with this problem. Right. So they've got several issues you need to address, including the deformity, not just of their foot and ankle, but the deformity of their tibia, which probably led to their ankle arthritis in the first place. And they're going to have about a four centimeter defect when you're done. And this guy is sixty five. He's got some medical comorbidities and he wants one surgery and he doesn't want that surgery to be an amputation. So here we go. So these are my interoperative images. This is the approach I took in this situation. So for those of you not familiar, this is the knee joint here. I think we talked about it earlier. But so this is doing what's called a reamer irrigator aspirator. I think it's a great way to get a large amount of bone graft without making big incisions or going to their crest. Sometimes proximal tibia can give you a lot of graft. I think I can get a lot of graft with doing a reamer and I think the morbidity is low if you're familiar with it. And so. We then go to correcting the tibial deformity, because I didn't think that I could correct their foot and ankle without correcting their tibia, which kind of led to their foot and ankle problem in the first place. So in the situation where we're already kind of hopefully gaining some adequate length with doing our custom implant that we're going to use, I elected to just correct through a closing wedge lateral osteotomy. So that device you see in that central picture there is a femoral distractor. So I put that on immediately to assist me with correction of deformity. We do our closing wedge. You then take your ball tip across. This is the custom implant that I use in this situation. You can see the clinical photo where it's packed with that Rhea bone graft mixed with some allograft and there are some biologics used here as well. And then this is him at one year follow up. So, again, his function was reasonable. I think one of the challenges with these custom implants is how can we actually assess healing with them? I mean, this is his CT scan at one year. Is he actually healed to that implant? How much is he healed to the implant? And I certainly think it will take a lot longer for this to fail than, let's say, a femoral head. So, yeah, I mean, this is something he luckily moved to Arizona at one year post-op. So I can only assume this completely healed and he's doing incredible. So future direction. So, I mean, a few things. I think that our ability to do arthroplasty for these people is expanding rapidly. And so I do wonder whether it's using a total talus or just using our already existing kind of revision technology, whether we're going to be able to manage some of these defects appropriately with arthroplasty. For those of you who have done any kind of limb lengthening or defect management with lengthening nails or transport nails, there's hind foot versions of that. And so I'm interested, certainly not a lot of data on it. I'm interested in the use of those to hopefully minimize the time and the frame for a lot of these patients or hopefully even take some people completely out of the frame. So in summary, follow your basic principles, understand the problem, the patient and understand what you can do. You can choose your own adventure and appropriately manage patient expectations. Thank you. Brian, that was amazing. Thanks for sharing all those cases with us. I think really expensive failure is probably the subtitle of my entire clinic. But thanks so much. We're going to do the last talk in this session with Jason Barreto, who's at Emory in Atlanta, who's going to be talking to us about biologics. Thanks, Jacob. Thanks, everybody, for having me to talk. Hopefully with this talk, we can prevent some of those non-unions so we don't have to do those crazy second surgeries. My disclosures are listed and they're on nothing sort of relevant to this talk in regards to biologics. So the objectives of this talk, I want to talk why ankle and hind foot fusions are different, why it's important, how it will affect your selection of biologics. We'll look at the current biologics that are available and then review a few cases if we have time at the end. So I want to talk first, thinking about types of bone healing, right? There's primary bone healing. Hematomas removed. This is our old wrist fracture when we were all residents. Slam the edges together, compress them. Fibula fractures. We do the same thing. Get a good compression screw. And they heal across with cutting cones and that kind of thing. And so understanding that and then thinking about secondary bone healing. You know, the tibial nail, the femoral nail goes through the inflammatory phase, the reparative phase, the remodeling phase. And so the reason I bring these up is how do our fusions heal? And that's been a lot of what my research has been here at Emory and understanding it, right? We have a bad ankle joint. We take away the surfaces. We poke some holes. We want the bone marrow to come in. And then sometimes they heal and sometimes they don't. And so are they healing through these methods? And I think it's important to think about that when we're starting to think how biologics may help the situation. And so how do fusions heal? I think the vast majority are probably some type of primary bone healing. They're ankle fusions like this, where they just sort of heal across the joint surface. There's no big cartilage that you see in your... But some of them are different, right? With the TTC rods, X-Fix, the Taylor Spatial Frames out there, they may be healing in a different way. And that may affect how we select our biologics. And so thinking about key parameters of fusions, right? We have these marrow-derived cells. We poke some holes. We want all this to come in. And how does that local environment affect how these cells go on, right? We do the same thing for a microfracture that we do for a fusion. But some of those cells go on to fibrocartilage. Some of those cells go on to bone. How do we affect that? We have these cancelled surfaces exposed to each other, and we push them together. That's not a classic sort of cortical edge, compressing them together. How does that work? And so which cells are populating? Which method of fixation is important? And how does that surrounding soft tissue envelope play a role? And so when we're thinking about fusions, the important thing is whatever you pick, you've got to put enough of it in there. It's a great study by DiGiovanni et al. They looked at CT scan at nine weeks out and compared those with 50% of the joint face filled with those with less than. They had 81% healing in the greater than 50% and 21% in the insufficiency group. So again, whatever you pick, make sure you put enough into the joint space. Second thing is, how do we define healing, right? There can be clinical, right? Patients are doing great. They don't have any pain. Can it be x-ray, CT-based? I think if you're going to do it in a study, you've got to define it by CT scan. It's a great study by Glazebrook. If you look at greater than 25% or less than 25%, it had direct correlation with improvement in FFI if you get more than 25%. So we don't have to do a great job. We just have to do one fourth of the joint has to heal. And that's what I tell my residents all the time is that we don't have to get 100% to heal. We just got to get a quarter of it to heal to get us a good clinical outcome. But even with that, we still have a lot of patients who go on to non-unions. Lastly, thinking about how fusions are different from a modeling perspective, right? This is a spine rat model up here where they just lay bone graft in. There's no compression. There's all this great surrounding muscle that we don't have in the ankle. And it's not a tibia fracture model, right? You're not just letting the bones sort of get this big envelope on that. There's reduced vascularity, reduced stem cells. We use rigid fixation. And so, you know, I've developed some preclinical models here in Atlanta. This is a rabbit going through a fusion. And so I don't want to hear anybody complain because I'm doing fusions with this size of a joint. And so, you know, anybody who wants to have a hard time doing a fusion, come do it with me and a rat, and I'll show you some challenges. I'm just kidding. But just to think about it, what we're doing here at Emory, this is just an example of getting compression. And we can do all these fancy things to look, but we ultimately have to figure out what to use. And so you want to think about a couple of terms as well. Osteoinduction, osteoconduction, and osteogenic, right? Osteoinduction brings the cells in. Osteoconduction provides a scaffold for them to grow on. And osteogenic means you put the actual alive cells from outside the body into the space. And so let's think about our current adjuvants. Autograph bone, you take it from the patient. We all know that this is still the gold standard, but we try to get away from it because there's problems associated with taking autograph bone, but it has all three of those things. We're going to talk a little bit about PDGF, talk a lot about PDGF, talk about BMP2, P15, which is coming out there, and some PRP. And then we'll review at the end. And so one last thing, got to have good technique, right? This is just some good examples of got to really expose that subchondral bone, get through the cortex. None of these adjuvants will replace good surgical technique. Got to really allow that bone marrow-derived cells to get to the joint surface. Got to get through the calcified cartilage and the subchondral plate. So thinking about platelet-derived growth factor, it's a potent mitogen, right? It expands cell population. So the cells that come in, they grow and expand. It's chemotaxis. It attracts those cells to more of the cells that wouldn't have come in, come in, and it allows blood vessels to grow. One thing I want to stress here is I didn't say it makes bone. And we have some really good preclinical data. And I know everybody's turning off because we're starting to talk about in vitro experiments. But basically, in 2D culture, we showed that it increased mineralization, but the gene expression isn't upregulated at all for cells that make bone. And so on a per-cell basis, it doesn't make more bone, but it just allows more of the cells that make bone to be present in the environment. And we showed that in also our 3D cultures in fibrin gels, which basically showed the same thing. And if anything, there's a hair of less mineralization in overall CT evaluation. And so just thinking about PDGF, and it's a great molecule, and I use it a lot, but it's not necessarily making bone, but it's expanding the cells that can work for you in your fusion environment. It's the primary molecule in Augment, but there are no animal studies or human studies with the carrier alone. And so that's another thought is how much is the carrier playing a role here? And so we'll go through the literature. This was the initial clinical study run by Tim Daniels. Prior to them doing their randomized control trial, 75% union rate, no adverse events. They then did a small pilot trial where they did randomize two to one, so 14 patients with Augment, six patients with autograft bone, CT describing union. So nine out of 13 versus three out of five said, not inferior, we're going to keep going. But even there, they identified graft site pain at three months. This is a very large study, probably the best done study in foot and ankle DG body at all. 434 patients, two to one non-inferiority. If you haven't read this study, you got to read it. It's a great study. 12% with graft site pain and clinical success was equivalent between the two groups demonstrating non-inferiority. Now, I didn't say it was better between the two groups, right? And there's even, you know, maybe if you look at the first CT scan, autograft was doing better, but overall it does a good job and can provide you the same benefits of autograft without the pain at the graft site. They also then did another study, modified it and added collagen into their carrier to see if that would help improve. And this is a good study, but I don't like it because they use their previous autologous patients in the group for comparison. And, you know, we all learn something when we do studies better. And so I don't know that this is a great study in the sense of, but it shows that they had 84% healing in their PDGF group, which I think is excellent. So when they subgroup and analyze that literature, it really showed that patients as they age, didn't do as well with autograft bone, which sort of makes sense. And that PDGF made up for that. And so age is an interesting thing when we're thinking about PDGF. And I sort of think about it more when my patients age, because I really wanted to expand those cells that are going to populate that fusion site. Just to talk about PDGF by some other authors who weren't associated with the Augment studies is 92 out of 98 Charcot patients, only 30 out of 98 had CTs, but 93% clinical success and a 26% complication rate. We'll go on to talk about BMP2 now. It's definitely used off-label in the foot and ankle, but there's some good preclinical studies. This is an excellent preclinical study looking at ankle fusions in a rabbit, basically showing that there's an increase in bone volume, increase in fusion rate, compared to autograft bone with using BMP2 off-label in an animal model. So what about some of the literature in patients? 45 patients, 21 ankles, 24 subtalar fusions. These are high-risk patients. They had no non-unions, two wound issues and some weaknesses though, right? No comparison group, no consistent imaging evaluation. But I think the key is, is the BMP off-label was concerned in the spine when they used it in the cervical spine because of swelling. We don't see the wound issues or some of the complications related to swelling. Again, another study on BMP2 looking at high-risk ankle and hind foot fusions, 96% fusion rate, no comparison group. They did add their own autologous bone in some cases, so it's a combination treatment in some patients. But again, very low complication rate, two wound complications and one deep infection. This is another retrospective review looking at ankle fusions with Alizarov, so sort of a different technique than sort of that we've described before. High-risk patients, they did 41st without BMP2 and then 42 after that with BMP2 and they increased their fusion rate from 56 to 93. So BMP2 had some success in sort of the same type of patients who were having an Alizarov-type frame. This is another case series looking at BMP2 and ankle fusions and non-unions. 47 out of 51 patients healed with 78 out of 82 joints, one deep infection, four wound healing complications. And I think for high-risk patients, that's some good literature to support its use. Again, no comparison group, no CT scan, no control. P15 peptide is another molecule biologic that's out there. It's a 15-amino acid sequence as the attachment site of osteoblasts onto type 1 collagen. It's the bioactive ingredient in I-factor. There's only really one good foot and ankle study, and I wouldn't call it good, but a sort of reasonable case series looking at patients treated with P15. Overall, a 92% union rate, but no CT scan, no comparison group, and definitely needs more. Its basic science data is all in animal models in the spine, and its approval is through the spine, similar to BMP2. So I don't think we know enough about P15 peptide yet. When thinking about platelet-rich plasma, it's blood that's centrifuged to remove the red blood cells. It contains the growth factors. And then PDGF is probably the number one growth factor that's in there. And so it may have some similar effects to PDGF on its own, but it's certainly not at the same level, but has all these other growth factors in there that may help. It's definitely being used sort of as a patient treatment, but no sort of big clinical studies or clinical proving it. It was first described by Coetzee using it to get the syndesmosis to fuse. He compared it with and without PRP in syndesmotic fusions with the agility total ankle, and they demonstrated enhanced fusion with the growth factor supplemented in. There is definitely other literature to support it, though. This is Bibo et al., 62 high-risk patients with 123 procedures, all surgeries supplemented with autologous platelet concentrate, 94% union weight, low complication. Definitely some weaknesses to the study, though. No comparison group, no CT evaluation in that regard. And so I've talked a lot, and I want to say again, if anybody wants the slides or anything, just email me. But thinking about what you need is important when you're thinking about your patients, right? You have ankle arthritis, and this is just a model we use for our grant proposals.

total ankle arthroplasty

ankle replacements

orthopedics

arthroplasty

bone healing

biologics

component alignment

bone grafting

surgical technique

joint fusion

robotics

personalized treatment

patient needs

mechanical stability

ankle degeneration