We're going to continue with some interesting and transformative stuff related to arthroscopy. Steve, who you heard from earlier, is going to talk to us again. Steve, go ahead, take it away. Thank you, Paul. I'm sorry you've got to burn me twice within an hour, but that's how the cookie crumbles and the talks have fallen. Can we have the slides, please? You can see more than I can. There we go. That's better. I'm going to talk about arthroscopic hindfoot fusion. No disclosures, and you've already seen that slide. Why would we choose to do things arthroscopically? We've already gone through these, minimized the trauma, less infection, hopefully improved the union rate, and certainly faster rehab and earlier discharge. This study concluded that there's not much difference between open and arthroscopic assisted techniques in terms of the outcomes for PROM scores and AFS scores, but they did have a much shorter rehabilitation time and earlier return to sporting activity. Just to prove the theme that we've been displaying through the whole of the day, really. How do we do subtalar fusion? The original description was the PASTER approach, a posterior two portal approach, to access the posterior facet of the subtalar joint. It's easy to do because it's familiar. We do, those of us doing arthroscopy, do posterior arthroscopy, and it's just an extension of that technique. In 2009, Nick Van Dyke modified it to include a third portal through the sinus tarsae. My chosen technique is actually the lateral approach, which is usually a three portal approach as well. I find it's easier positioning on the patient, you don't have to patient prone, and you have the ability to extend that into the anterior middle facets if necessary. Is there any reason to pick between the two? This one paper gives us some evidence that if you do the posterior approach with just two portals, then the non-union rate is eight times as high. I think the conclusion from this paper would be that you either use the three portal approach, posterior or lateral. My approach, again, traction is not really used. We have them in the lateral or the floppy lateral position, which I'll show you some slides of. Again, as I said in my last talk, generally once you're familiar with this technique, use a large scope and a large shaver because it's quicker and more efficient, but you can use a small one in particularly small individuals or if you're learning the technique. I have them on the side with the foot suspended over the edge of a block, such as this, just opens up the sinus tarsi and the lateral approach, and then we can prep them up in this position. The portals we use generally start with two sinus tarsi portals, as indicated by the dotted circle, and then once the procedure progresses, we add in the posterolateral portal. Initial insufflation of the joint, just to identify, more than trying to get fluid into the joint, it's just to identify that you're in the sinus tarsi, so make sure the needle passes a good distance into the sinus tarsi, and then this is the initial approach. It's difficult, again, as I said, the two instruments are very close together, the portals are close together, and very fine movements does make it awkward, so it's a technique that has to be mastered, but it is technically possible. The first thing you come across is the interosseous ligament in the sinus tarsi, which needs to be debrided. You'll see from the image on the right, the positioning of the instruments and the scope, so this is a right ankle we're doing, and the posterior facet is off to the left of that image. And then we get in with the proper instruments, the burr and the shaver, following the posterior facet. The subtalar joint, for those of you who have not been in there with the scope, it doesn't open up like the ankle joint, you can't get the instruments actually into the joint, or very unusual for you to be able to do that, and so you're actually creating the space by burring backwards, following the seam line of the joint. Once you've got it so far back, it's helpful to have the post-lateral portal, which you've seen introduced here, so this is coming from the post-lateral side. It's important when using this technique to clear the very edge of the joint, and make sufficient space to give you a working arc for the instruments. If you don't clear that space right up against the edge, once you pass the instrument further across the joint, it has a restricted range of movement. And you consider that you continue the dissection, the resection of the joints as far back as you possibly can reach, and ultimately the goal is to see the FHL tendon moving at the back, and at that point you know that you've reached the appropriate point. So there we can see the FHL moving comfortably, and there's a satisfactory resection. So this is the appearance you might like to have in the posterior facet, seeing the nice sinusoidal appearance of the facet, with good healthy bleeding cancellous bone, suitable for fixation. The fixation I've traditionally, originally used, was a single screw, such as this, and I had no real problems with it, but then several papers came out, including this one, showing a higher rate of non-union with single screws, so now my favorite technique is to put two screws in, but because I'm putting two screws in, I tend to use countersunk screws to achieve a stronger fixation, and hopefully reduce the complications of prominent screw heads. So my post-operative regime, these cases are all done as day cases in my practice, unless there's medical factors for the patient that prevents that. They all have DVT prophylaxis in the form of aspirin, they have a plaster on for six weeks and a boot on for six weeks, I get them weight bearing relatively early, in actual fact I'm not unhappy if patients start weight bearing straight away, it's just to encourage them to rest a little, and we x-rayed them first time at three months. So my local series, we have 77 procedures with a 97% union rate, one infection and one nerve injury, and this fits well with the literature, where there are plenty of studies showing very good outcome from arthroscopic subtalar arthrodesis, with a satisfactory improvement to the AOFAS score, various papers have shown a higher fusion rate in the lateral approach, but lower complications with the posterior approach, I don't think there's much to pick between them in terms of a pure subtalar fusion. The final paper, a review of quite a large series, same sort of figures, with relatively low complication rates, the biggest one being metal irritation in the heel of the foot. So then the next stage comes, can we take this any further, can we move on to double or triple arthrodesis, well we can, and we start with the same portals, but we do need to move on and use some additional portals, as indicated on this slide, with a dorsolateral, which is generally the workhorse, possibly a dorsomedial, a calcaneocuboid portal, and possibly some people in the Far East describe a trumedial portal, but that's awkward to use, particularly if you've got the patient in the lateral position which I showed you, so that's not a favoured portal of my own. And the way to do this is to extend basically what we've just seen in the last three or four minutes with the subtalar joints and then just extend it anteriorly into the middle and subsequently the anterior facets, which you can see in this arthroscopic picture. This will necessitate the use of the dorsolateral portal, and then through the sinus-tarside portal you can go anteriorly, once you've cleared those facets, and you can look down into the calcaneocuboid joint, which we can see here, and then again, sometimes it's accessible through the same dorsolateral portal, but if a supplementary calcaneocuboid joint portal is required, then that's fine, you can resect the full depth of the calcaneocuboid joint. By this stage, the hindfoot is loosening up, and you generally get a good view of the lateral edge of the talon-avicular joint, as we can see here, and again, through a combination of the portals I've already described, you can begin debridement of the talon-avicular joint across medially, and ultimately achieve a reasonable clearance of all three of the hindfoot joints. Fusion is all done percutaneously with cannulated screws, there's no particular method that I recommend over any other, this is one particular pattern of fixation, and that's the same case six months down the line, so a satisfactory fusion achieved in the joints, and good outcome. Another clinical case example of a severely planovalgus foot with a virtually dislocated subtalar joint, with an arthroscopic double fusion used to get a reasonable correction of what was otherwise a very technically demanding procedure, and would have required a substantial medial approach, probably. So the results, I can't give you good evidence for this, the results just don't exist at the present time, we're still in the learning curve of this procedure, this paper from the southwest of England, a colleague of mine, Steve Parsons, he's just done 18 cases with four of them triple and 14 doubles, he's had a union in all the triple, but significant non-union rates in some of the doubles, so more work is needed to analyse and modify this technique so that it can be brought regularly into practice. So in summary, subtalar arthrodesis I think should now be as easy and as straightforward as we accept arthroscopic ankle arthrodesis, it's reliable, union rates are comparable with open procedures and the complications are fewer, and the rehabilitation is much shorter, like we've done as a day case. Triple arthrodesis on the other hand is a bit more technically demanding, there's definitely a learning curve and you need to be very familiar with arthroscopic techniques, and we need to have longer term follow-up and results of this before it will reach a stage where it can be disseminated widely. Thank you. Thanks Steve, along those same lines, Andrea Vukovic is going to speak to us in regards to the arthroscopic ankle arthrodesis, Andrea. Well perfect, thanks so much for having me here guys, I have no disclosures pertaining to this talk whatsoever. We'll look a little bit about introduction, etiology, treatment options, literature and learning cases, and I think that's always relevant. What we know is that ankle arthritis is a major source of morbidity in a younger cohort of patients than those that present with knee and hip arthritis, however they have a similar effect to their function and morbidity. In general ankle arthritis can be staged or graded into four stages, stage one which is basically no inter-articular deformity, stage two more than 10 degrees, COFAS type three which is Planovalgus caveveris, and COFAS four which is basically Peri-Taylor degeneration. This helps inform a little bit about the treatment that you want to do and what treatment algorithm you want to do, however what we know is that ankle arthrodesis is still considered a viable treatment option for all ages, and there's currently no evidence that indicates that total ankle arthroplasty is superior. You have two techniques, one of them will be discussed by my counterpart which is on open ankle arthrodesis as well as arthroscopic ankle arthrodesis which I absolutely love if I'm going to choose ankle fusion. In general the key thing is if you're doing it open or arthroscopic you need to make sure that it's aligned, that's the key. Arthroscopic ankle arthrodesis has gained momentum with some studies indicating faster fusion rates and shorter hospital stays in open ankle arthrodesis. Recent studies by my counterparts have shown that arthroscopic ankle fusion is having some better outcomes in open ankle arthrodesis. We actually looked at this and published this in JBGS but we looked at it in one specific cohort so that we could compare apples to apples versus apples to oranges, and we compared basically isolated non-deformed ankle arthritis. We looked at their AOS pain scores and followed them appropriately with this. In general what we actually found which is interesting is that arthroscopic ankle arthrodesis and total ankle replacement had similar effective outcome which is significantly better than open ankle arthrodesis and what we also found is that this is true for the total scores and for the disability scores. However total ankle replacement did undergo more re-operations subsequent to the index procedure but they did not undergo more revisions so similar revision rates between the three cohorts. In the end what we learned is that arthroscopic ankle arthrodesis resulted in comparable clinical outcomes as total ankle replacement for non-deformed COFAS1 type 1 ankle arthritis. Open ankle fusion actually had significantly poor outcomes in this cohort and total ankle replacement did very well but had more additional surgeries with similar revision rates between the three cohorts. Overall when you think about this total ankle replacement and arthroscopic ankle fusion have equal or fairly good outcomes for short term follow up as long as you counsel patients that if you do a total ankle replacement they may need more adjacent procedures. So then the question is can you do ankle arthroscopic fusion in anybody? I personally think you can however there was substantial perioperative frontal deformity was considered to be a relative contraindication. In some papers and studies they said that more than 15 degrees of valgus or varus was not indicated for arthroscopic fusion. However newer studies have shown that arthroscopic fusion is still feasible in ankles with coronal malalignments. There's little information available about the effect of perioperative malalignments on the outcome after arthroscopic ankle arthrodesis. So we studied this and the study that we assessed was whether preoperative coronal ankle joint deformity influenced the outcome of arthroscopic ankle fusion. We followed the patients and assessed their AOS and AS scores and then we looked at their perioperative deformity and what we found was that perioperative deformity was the same regarding sagittal alignment and overall coronal alignment. However one thing we did note was that the arthroscopic group had fewer tibial deformity which I think personally as you get more facile with scoping you can address by burying out that side that's actually lower. So in final follow up what we found was that the arthroscopic group and the open group had similar outcomes. Most groups had the same tibial-tibial angle, lateral tibial station and lateral tibial-tibial angle at follow up and then we regressed and we found that there was no influence of type of surgery or preoperative deformity. In conclusion in patients with coronal and sagittal joint deformity arthroscopic and open ankle fusion yielded equivalent results in terms of patient reported outcome and radiographic measures and there was a higher tibial-perforant angles they underwent more open ankle fusions. My technique in general is that I scope everything and for me all of my fusions actually undergo an arthroscopic fusion even revisions. However if hardware is present and I have to get a plate out then I would do an open fusion. Foot realignment is always done if malalignment exists and I make sure that I look at the bony morphology and the soft tissues that ensure to address this at the time of the procedure. In general my approach to this is if a patient is valgus or medially gaping or translated away from the lateral malleolus then you can actually compress medially with a partially threaded screw, strut out laterally with a fully threaded or a long partially threaded screw, consider doing potential lateral soft tissue releases, consider an endoscopic or in your case if you want an open gastrocnemius recession and consider doing a potential peroneus brevis to longus tendon transfer, detention, the abduction of the foot as well as add to dynamic plantar flexion of the first ray. If the patient is varus or laterally gaping then you want to consider compressing laterally with a partially threaded screw, strutting out medially with a fully or a longer partially threaded screw and a potential medial release. Then this is the tricky cohort for me actually are those patients that are anterior translated. For these I really like to start with that endoscopic gastrocnemius recession or open recession so that you can actually detension the back of the foot and drive that foot back and diminish that lever arm. In order to do this you need to resect that posterior tibia. You can even consider using a home run screw to suck that talus right back towards the posterior malleolus and you may need to strut them out anteriorly so they don't collapse. So here's a few examples of that. This is an example of a patient with a ball and socket ankle. Unfortunately you can see that the patient has significant valgus hind foot alignment. In this case after doing a meticulous release laterally via a scope and also using a bank cart rasp you can compress medially as you can see here with a partially threaded screw driving the construct over and then you can strut out laterally so that you don't collapse. So I think it's important to do that. And you can see here once you're done that you have an improved alignment of the hind foot as compared to before and you have now space under the lateral malleolus that you didn't have before. Another example that I showed you before, this is a 37 year old who unfortunately has varus non concentric ankle degeneration, had a very interesting surgery done in Mexico where they fixed his os subfibular and has anterior translation of the talus and almost acetabularization and anterior translation of the talus and the mortis. In this case, it's extremely important to bring this talus back. This is a young person, 37 years of age. You have to get that lever arm diminished so that they don't cause that nutcracker effect in the midfoot. So here, obviously, I think the key is that endoscopic gastric recession. You want to detension that posterior gastric where you mis-pull the things back. You want to make sure that you resect that posterior tibia. You can use fluoro as your guide, so sometimes I have the C-arm set up so that I can actually burrow the whole back of the tibia, ensure that I can actually posterior translate. You may need some bone graft substitutes available to fill in that void. And then, in this case, you did a posterior lateral pulling screw to get that talus back under the tibial axis, and then strut out anteriorly, as you can see here. And then that's actually nice. You think, hey, is this going to fill in? Well, you know what? It does fill in. If you're careful with it, you get nice, meticulous fill up of that space. And that's significantly better in terms of the alignment. You have a nice improvement of that anterior translation with an improved lateral tailor station as compared to before. This is another case. This is a 55-year-old patient, unfortunately, history of a ankle fracture that resulted in infection. Infection was treated in the periphery. And you can see here that the patient is in significant valgus. They have opening of this space in the syndesmosis, and they have hind foot valgus. In this case, we actually did a scope fusion of the syndesmosis, okay? And you can see this large gap that's present after. So you actually make sure that you fuse that syndesmosis, put in bone graft substitute as required, and of course, make sure to floor your hand as much as possible. Put your bone graft substitute in, compress medially so you can correct that underlying alignment. Make sure you strut things out so that the construct doesn't collapse on you. And compress medially, as I said, and strut out anteriorly. And you can see here that that's an improvement of that overall alignment. In this case, the patient still has hind foot valgus. So here we did an endoscopic assisted calcaneal osteotomy, cotton osteotomy, and improved the overall alignment for the patient with good fusion, good realignment, nice closure of the syndesmosis, and a nice neutral hind foot subsequent, and nice fill of the space. Finally, you have to ask yourself, when is too much deformity too much? Can you always do something like this? Here's an example of the power of doing an arthroscopic ankle fusion or some form of fusion. Because in people with compromised soft tissue envelopes, these are the best people to consider these minimally invasive approaches. This is a 77-year-old diabetic male who unfortunately had a bimalleolar ankle fracture. He developed Charcot, had multiple surgeries done in the past, complicated by infection. He had this treated meticulously, had normal inflammatory markers, aspirates proved negative for infection. Hemoglobin A1C was improved to a level of seven after. And that's how he presents. So not really very many good options for this guy, right? You can see that he has that lateral translation of the calcaneus relative to the tibial axis, poor bone quality. Obviously, it behooves you to talk about conservative treatment for him, to consider below knee amputation, which was discussed, and he didn't want, or try something different. In his case, we did an arthroscopic fusion, took down that fibrinous tissue meticulously, prepared the bone meticulously, fused, and then used Aliak Crest trichotical strep grafts to fill in the voids, put a nail in, ensured that we put the nail just one figure breadth below the tibial tubercle in case he needed to have an amputation so you don't burn that bridge for yourself. Confirmed in three months' time that he had good fusion with a BTB-type cast. And then you can see here improved alignment in terms of where he's at. Soft tissues are improved, and you get a nice fusion mass. So in summary, arthroscopic ankle arthrodesis has the potential to be the superior fusion technique. It's inherently minimally invasive in nature. Because of the MIS, you have less pain, less swelling, fewer wound complications. Open and arthroscopic outcomes are equal in deformed ankle arthritis, and arthroscopic outcomes are better in non-deformed arthritis versus open. Key is that you want to ensure the deformity is corrected and the ankle is positioned anatomically regardless of technique. If it's not, make sure that you open it. Don't forget to address the foot with a prior bony and soft tissue corrections. And scope everything and every patient you can, and each scope we do will make you better at the arts. So sorry I'm a minute over. Thank you, guys. Thank you, Andrea. Now to hear the other side of the argument, we're going to bring on Christopher Reb to talk about why he still does the open technique. Okay. Thank you, everyone. That was a great talk, Andrea. Always inspiring. Okay. So my job here is to talk about open techniques. And one is said to be mumsum as if they are adherent to tradition despite the fact that it's proven to be a method that's outmoded and ineffective. But at the same time, oh, yeah, no conflicts, I should talk about these learning objectives and maybe give you a different perspective on open techniques than we've heard so far. So one is to identify indications for using open techniques for the ankle in terms of fusions and fractures, especially then to focus on each to extol the virtues of open technique. I remember reading this in college and thinking, man, I don't want that to be me. I certainly don't want to be unskilled and unaware of it. But if we look at all the arthroscopic techniques that are available now, and we look at all these folks who are proficient and we try to incorporate that into our practice, that's quite a lot of change to implement at any one given time. The one that I decided to start with was for the ankle. But this is what our experience looks like. This is an individual and a collective experience that you start out, you start to put something into play, and when you go out and practice, all you have is your wits and your experience, and then you have a whole new set of problems that you didn't encounter. And so you hit the peak of Mount Stupid pretty quickly, but if you persist, you go into the Valley of Despair, so that's a reward for perseverance. And then as you come out the other side, eventually you actually start to become truly competent and effective at what you're doing, all the while thinking, but I already know how to do this open, so why am I forcing this? But it is also the case that the open techniques are there. They are old faithful. And in the name brand, highly reputable places where I have managed to get a job, it is still the case that insurmountable preparatory defects occur, and quite regularly. Equipment does go missing, it breaks, they only brought in one set of it, there are times where they put you in a room not big enough for what you intended to do, or the staff is just not going to set you up. And so sometimes you have to be prepared to think on your feet and change. It is also, I've always worked with residents, I tend to get the junior residents, and open techniques are part of a well-balanced training track. They also make people better at arthroscopic techniques. Much of what we accomplish with these arthroscopic techniques are things that we learn from the way we learned them doing open. And so, especially for our trainees, I find that they need both. It also happens to be, if I want them to go into foot and ankle, they're going to want to get their hands on things, and it is usually a little more familiar with the open techniques. It's not the primary reason to do it, but it is a good reason to do it. And of course, then the cumulative skill acquisition occurs, and I love when they come back from other rotations and quietly thank me for things that the other guy said they did well. But primary open ankle arthrodesis, it does work. We were motivated to do this retrospective review just to look at whether bone grafting was appropriate and indicated on a routine basis, because it didn't seem so in my practice, it didn't seem so in my fellowship experience. And when you look across a lot of these studies, they're done open, and they're just fixated with screws, and of course if the right criteria are met, you don't need to graft it. The graft is there if you have gaps, defects, maybe patient factors that are contributory to non-unions. In this study, you needed seven patients to not, grafting was unnecessary, you had to treat seven just to prevent one non-union, so absolutely not for a primary indication. But it suggests that primary ankle arthrodesis done through an open approach works just fine. That's not a high enough level of evidence. If you try to scale it up to a claims database like Pearl Diver for here in the United States, you get a really obscured picture, 11% non-union rate, but this doesn't tell us what the re-operation rate was, this doesn't tell us how technically difficult they were, it doesn't tell us a lot about the patient factors, but of course the usual players, diabetes and comorbidities. All good reasons to know how to implement the arthroscopic technique, but not a good reason to totally abandon the open. If we look at the Canadian study, looking at open and arthroscopic five years out, it is the case that they used the open for the harder stuff, but they still got comparable patient reported outcomes in a very low rate, and we know they're skilled, and we know they have good patient follow-up, and we know their data is a lot cleaner, and so this is again, it doesn't just suggest that arthroscopic is a good technique, it affirms that open is a good technique. If we look at a single surgeon's case series, retrospectively looking back at prospective data with okay sample sizes, another separate but general outcome measure suggests that it's really not that much of an improvement to do it arthroscopically, it's a perfectly valid and good way to do it, especially if you do it right, but it also affirms that the open technique is good, and even that statistically significant difference at six months, if you look at the real numbers there, probably is not clinically important. And what if we try to pool studies like this, Park did a systematic review of level three or better studies, and again, you see a nice wide range on union rate, not because how we judge union and label it has a big difference in what we measure, but it also starts to open up this conversation to talk about the impact of hardware, which is really a technical factor, not an open approach factor, and screw constructs, just like we saw, you have to use them right. That picture, second one in from the right hand side there, I mean, that's not going to work, you have a valgus deformity, you have screws that are not in a mechanically advantaged position, I think we just heard Andrew say that you would start on the medial side, suck that thing in and get it right, it might not look like that. If we go in the middle picture, if you've used a washer on the medial malleolus, if you get it to sit down, it's wonderful. If you don't and it sticks out like that, you're going to be taking it out later. So hardware removal rates can really obscure the picture, and I can illustrate that further. But let's look around, look at this UK study, there was comparable hardware removal rates, this was not an open problem, it's not the fact that they did it open, I'm sure they're very good at both techniques. When I was in fellowship, I decided that the anterior approach was getting a bad rap, that we do close it and get it to heal very nicely, so I decided to look at just our anterior approach for ankle arthrodesis, this was all done open in ankle arthroplasty, and what we found was that just being really critical, you know, saying that there's still scab on the surface of the skin, it was a pretty high rate 30 days out for both of these techniques, but it was actually better for the arthrodesis. And then when you look cascading down from that, we had in-house wound care. Having a wound care specialist can really make the overall re-operation and complication rate change quite a lot, because they're going to culture wounds, and they're going to get things to heal, and they're not going to go back to the OR. And so our takeaways from that experience was that, yes, the anterior approach can take longer to heal than you'd like it to, but wound care works, and since they're actually culturing things, you're going to have a higher documented rate of infection, but it doesn't mean that the approach was bad. And then it's also important to understand how hardware is not the approach. That picture right there, I mean, that's begging for wound problems, but of course, just as the point I'm making, you take that hardware away, and things heal up. It is also a pretty important context to consider that during the time of that study, my fellowship practice, they were going through the learning curve of the anterior locked plating technique for ankle arthrodesis, and they were abandoning the screws, and that's what the plate fixation column and the screws alone column indicate there. But even when you look at that, through the learning curve, where this should be the highest rates, their later on removal of hardware, which was mostly the inner fragmentary cannulated screws, was still better in the anterior locked plating. So not an approached problem. Here's a study looking at dual approach, and I know in my experience at tertiary centers, there are times where I've had to go to a dual open approach because of maybe medial sided pathology, and in this surgeon's outcome, following patients for two years, they had good improvement in clinical outcome scores and a low complication rate. It doesn't mean that everyone's immune from complications. I have plenty of them myself, but it is entirely feasible, and I think this gives a voicing to what a lot of people in this room's experience is with ankle arthrodesis. I love doing it arthroscopic and getting better at that. I like the growing ability to take on more technical things, but I certainly don't look down upon having to do it open. The other wonderful thing to happen for ankle arthrodesis is arthroplasty. Both of these cause us to go back and look at what we already know and study it anew, and a lot of what that does is affirm that we're already doing pretty good work and that the overall complication rates are not as bad as we tend to utilize when we're trying to set up a clinical problem in an introduction to our articles. If you look at the utilization of TAR in the Pearl Diver database, I mean, obviously it exploded and the two techniques reached parity around 2013. This is great for guys who like to do open technique because it means here come the complications, and at least in north central Florida for a couple of years, they came to me and I was glad to have them. But you're also going to open up the can and do a whole variety of open techniques with highly variable results because this is an enormous problem. Thank God for revision arthroplasty and as many people are entering the freight to solve some of the problems and prevent this, but it gives new life to open technique. Most of these you can't even begin to think about doing arthroscopically, but give Andrea about another two years and she'll have that solved too, no doubt about it. Some deformity corrections, again, this is now something in my wheelhouse that I can do arthroscopic, but maybe not if that's entirely inflexible and it's very hard to release and it doesn't reduce, but Todd Irwin can easily do this open and get good results and I'm sure do it in a time efficient fashion. You have some deformities that you just cannot tackle arthroscopically, revisions of ankle arthrodesis like this. Here's a case of my own. We were consulted to convert it to a TTC because of that subtalar arthritis, but she had midfoot pain because it was too aquinas, so I just did an anterior closing wedge mortise cut osteotomy, revised it. It meets all the criteria. You know, you got good surface area for bony contact, it's mechanically stable, you can weight burn right away, you can use a very small approach. Great indication for open, glad to be able to do it, wearing socks that she bought me. Peel on fractures, again, it is now no longer the abhorrent idea that some of these patients may need to go to a primary fusion, although to be fair, open reduction internal fixation is still a parity with fusion when we look at patient reported outcomes in the literature. But infix and exfix, you're going to have to use open and if we look at the complication rates, especially if the patients who need it staged, we're going to have a higher wound problem. That's not only because we're doing it open, but perhaps in some of those staged patients, when we go back, we could do the joints prep arthroscopically and maybe cut down on some of the complications if it is coming from open. But what about all those primaries that were done open and have a very low complication rate? So there's a lot more going on there. And as we seek into other fracture care, you know, there's percutaneous and minimally invasive techniques and they're very important. And especially the complications that we see are mostly tied to patient factors, so we get smart. We use them in patients who are at higher risk and I completely agree with that. But we also have to bear in mind that malreduction is also more common in the harder fractures, the trimals, those ones involving syndesmosis. And it does matter. Things that seem relatively innocuous, like the vector on your clamp, they can have really important biomechanical impacts and cause real problems for the ankle. So while we're motivated to do the MIS because we can and it's good for wounds, we're also taking on some of the tougher things that have a higher rate of malunion and we have to watch out for. And even subtle malreduction can have big impacts depending on how accurately you measure it. Of course, there's no shortage of really good ideas to help us do that better. Examples that you can find in the research showing how to do that percutaneous but achieve more comparable to open outcomes. But even then, you've got to watch out. Here's a study we were motivated to do because it seemed like a clamp was always pointing right at the saphenous nerve. Seemed like our medial aperture for flexible fixation was always at the saphenous structures and it turned out in this cadaveric study it was common. So I think these are things that we have to consider as we're trying to implement arthroscopy into our practice. So in summary, I still very much feel that the open techniques are indispensable. And they're certainly there when the indications are outside the range or outside your range for arthroscopy. And that the primary open techniques are still relevant. They're still safe. And they're still effective. And especially when you choose the right patient, you can get a good result. Thank you very much. Thanks, Chris. Jonathan Backus is now going to talk to us about arthroscopy as an adjunct for ankle I didn't know we were gonna get entrance music. I would have picked something probably a little bit different. Anyhow, my name's John Backus. I'm at Wash U in St. Louis, and I'll try to keep us on time here. These are my disclosures. Let's start off with a case. It's a 38-year-old female distance runner who fell down some icy stairs. So this is a really active patient, and she has an injury that everybody in this audience knows how to fix. Our traditional methods for doing this work, right? Radiographic assessment to determine the need for surgery, as well as to fix the fracture, as well as open alignment assessment, works. We all know this works. Yet, several studies have suggested there's still a proportion of patients who have unfavorable midterm and long-term outcomes, and this is likely multifactorial. It could be additional injuries, such as cartilage injuries or ligamentous injuries, or articular malreductions. So my question to you is, should we scope ankle fractures? And is it possible to take an injury that looks like this and try to prevent it from becoming this? So back to our case. Oh, sorry, go back here just a little bit. So if you look at this carefully, I don't see any chondral lesions or osteochondral lesions. You know, this looks fairly run-of-the-mill, and I think this patient would do quite well. But if you look at the scope pictures, right away I can see a large chondral injury. I can remove that from the joint, and then I see comminution in the intermediate corner of the ankle. I can adjust this as well, and I can tell her that the rest of her cartilage is okay, and this is kind of what we picked out. Following that, we'll just use our traditional techniques to do a nice open reduction internal fixation. So I can help prognosticate this injury for that patient. We all know that there's a little bit of a problem with the intermediate comminution, and this can change our outcomes, and I can tell the patient that. Moreover, there's a potential for me to intervene in these cartilage injuries. And we all know that patients who have chondral lesions with ankle fractures do worse than those who don't. So this is a nice paper. Showed 100% chance of cartilage injury and a fracture. So this is a patient of mine, 45 years old, who got a little wild at a Cinco de Mayo party and fell off a table. I didn't ask her why she was up there. And this is what we saw. You know, her x-rays aren't all that dramatic, but this is a large piece of cartilage taken right off the weight-bearing portion of the tailored dome. So even though we can fix this fracture well, I can tell this patient that she's gonna need something else in the future. So it's not always so subtle. This is a 34-year-old male who is moving into his house, so I can tell my wife now that not only is it terrible to move, but it's also dangerous. And he fell and he broke his ankle. And if you look at this carefully, he's got an osteochondral lesion of the talus. And a lot of you would say, well, that's probably incidental as opposed to a medial lesion. It's probably been there all along, but I'll argue if you don't look, you don't know. And so in this scope, you know, this is the EATFL that's ruptured. Cartilage looks okay so far. I'm assessing the syndesmosis. We'll talk about that a little later. And then I start to see a little bit of grade two, three changes, and then here on the medial corner, he's now sheared off a full-thickness piece of cartilage. And if you look where his osteochondral lesion was, this is a large unstable lesion. I would have known that if I just assumed it was an incidental finding. So I can remove that, I can prep it, and then I can microfracture it or just debride it, depending on what works in your practice. And this is what we end up with. Following that, we do our traditional AO techniques. So why do I scope ankle fractures as well? We all know that there's inflammatory cytokines in the ankles. Sam Adams helped us understand this, and that even after the ankle fracture heals, there's still inflammatory cytokines in the joint. So does arthroscopic assessment of the joint allow us to lavage and reset the inflammatory milieu of the ankle and potentially decrease ankle arthritis in the future? So I also would argue that it's great for ligamentous stability. I know there's been other talks today, and there'll be talks after me, but this is a posterior shuck chest on the left, and then this is the drive-through or an instrument, a cotton test, it's a 3.5 millimeter shaver. You know, from Guyton's study, that seems to be the magic number. And some would even argue that arthroscopic assessment of these ligamentous complexes are better than fluoroscopy. Oh, okay, so this, even after you fix the synesmosis, this is pre on the left, I put a tightrope in on the right, and I can also use this to not only assess my reduction, but the stability following this. In addition to this, in some select cases in the medial malleolus and the posterior malleolus, you can also use the scope to help you aid in articular reduction. So this is a patient with a fairly large posterior malleolar fracture, but looking at it, it's not that bad. But I can use the scope to look at this injury, assess the cartilage, and also reduce it through percutaneous techniques. Then we can perform some regular fixation, and final fixation, and potentially alter this patient's outcome. And lastly, I would say it's safe. It only adds six to 15 minutes, depending on what you read, if that's important to you. And there's been several studies now that show there's not an increased risk of complications with scoping your ankle fractures. But what are the outcomes? So these are two papers I like to talk with with the residents. The first is out of Houston, and what it really just says is, if you don't look, you don't know, 75% of the patients in our study had a new diagnosis with ankle arthroscopy, and then 34 of them had 40 additional procedures. Now a lot of people would argue, what are these procedures doing? And we don't have the answer for that yet, but I can tell you that these are potential interventions that can prevent arthritis in the future, and we're gonna need some longer term studies to understand that. There's a propensity match scoring article out of Germany, and they found that the OMAS and FAM scores are better in the arthroscopically assisted group, and that the sports score, as well as the return score, was higher in the arthroscopic group as well. However, the heavy hitters in the American literature really show you that the patient reported outcomes are equivocal. So I don't scope every ankle fracture. Just because I'm a hammer doesn't mean I'm a nail, right? So I usually won't go after people that have a simple Weber B, that I'm confident doesn't have a post-traumatologic fracture or an older patient I'm worried about comorbidities and getting them off the table, but I do think that this is something that can help us prognosticate outcomes, intervene on large cartilage injuries, the cest ligament disinjury may be even better than fluoroscopy, lavage the joint of inflammatory cytokines, and potentially even aid in articular reduction. And hopefully this will result with better mild and long-term outcomes that mitigate post-traumatic arthritis. So we do need some long-term studies, and I also think that we need some studies comparing patients we have known injuries. You can't just take all comers and say it's the same, that's too broad. I think that for the group that says, oh, I just address it open, we need to compare that to things that are treated arthroscopically. And I think that we may find in the future that this is a little bit like how we felt about the rotator cuff, maybe 15, 20 years ago. You can assess the joint better through a scope than you can open. And that's what I have for today. So thank you for your attention. Thank you. So really we should look at, we talk about scoping for syndesmosis, we're going to look at the recent literature and discuss techniques for diagnosis. And then the only real important trophy is the beanpot. So factors in play in terms of syndesmotic, you have to really decide unstable versus stable, that's the most important thing. And so you can have injury but not instability. And so for pre-op workup I think that really is going to give you the design for how you're going to manage your patient. And so if you're suspicious I use this five centimeter proximal to the joint clinical exam and I want to get axial views whether MRI or CT scan and then consider dynamic testing as well. Our office has a mini C-arm that I'll oftentimes use. And my new preference for me is weight-bearing CT scan over MRI if I have to choose just one exam, do the dynamic nature of it. And the bilateral comparison which our lab has done some extensive work on. And if you're not sure it's acceptable to do an exam under anesthesia but your pre-test probability is pretty high if you're taking the patient to the OR for a syndesmotic problem. So athlete versus non-athlete, if you're going to fix the athlete are you actually going to get them back on the field quicker? That's one of the concerns. And so you'll see the high school kid with maybe seven, eight centimeters of syndesmotic discomfort the day or two after they present and after the injury. And then they magically get better and they're back playing in two weeks. And so you don't want to necessarily jump to fix them because I don't think you're going to get them back faster. And then really fixing your non-athlete is going to get them back to work and normal life quicker. What are the risks at play with this? And is there really a syndesmosis you regret fixing? And I would challenge someone to tell me about that. So anatomically I think everyone knows the anatomy and then what you can really see in the scope portion. So the AITFL, interosseous ligament, interosseous membrane, PITFL, inferior transverse ligament. For me arthroscopically I'm really focusing in on the PITFL and the interosseous ligament membrane. Historically looking at this 1994 study it was medial lateral diastasis was assessed through eight cadaveric specimens and the AITFL contributed to 35% stability than the deep PITFL. Dr. Clanton's study was a cadaveric study looking at the AITFL showed a 24% reduction in... So, our Farrell lab has done extensive work on syndesmotic. Apart from our lab, recommended that we do stress maneuvers off traction. So, this works well just to remind you to test people off of traction, take them out of traction if you do use traction. And then sagittal plane instability of greater than 2 millimeters is unstable. And syndesmotic instability is obviously a multi-planar issue with fibular translation in the sagittal plane. We also looked at coronal plane and looking more at the posterior margin of the intrashear being more sensitive than the anterior margin for diagnosis. And clinically speaking, you're usually getting a CT scan or an MRI so you'll sort of know what part looked diastased more than maybe the contralateral side to assess as well. So, looking at a lateral hook test, we found the syndesmotic ligament injury results in coronal plane instability of the distal tip-fib articulation. That's readily identified arthroscopically with a lateral hook test measured in the posterior third of the intrashear. So, clinically, it's relevant because when you're doing this lateral hook test, the tip-fib. So Dr. Guyton's study tried to challenge this 2 millimeter historical kind of benchmark for syndesmotic and so he used a 3 millimeter ball that he, that was felt to be a bit better and so most of the shavers that we use are in that range. I use a 2.9 so I just use a shaver since I don't have this, this ball available. A medial drive through sign was described by Dr. Dracos basically using the somewhat blunt object to push through on the inside of the joint to see if there's instability as well. You should do it before and after fibula fixation. So how do I do this? I do my typical arthroscopic intermedial and interlateral portals and then you should be testing off traction and you're looking for hypermotion in the sagittal plane and or easy penetrance of an arthroscopic shaver. For me it's a 2.9 into the syndesmosis. You can also look into like a drive through sign for the actual syndesmosis and I'll show an example later on where you can actually drive the camera up into the syndesmosis and that's obviously an unstable injury. And especially in the fracture setting you're looking at this PITFL avulsion fracture posteriorly and there's usually a little small cartilage injury associated with that as well. So one of my, one of my cases was an Ehlers Danlos patient that had a modified brostrom and an ankle scope and then she failed this. And so we were planning an allograft reconstruction. fixed and that was not part of my pre-op plan for her, it was just to do the allograft reconstruction. So we ended up fixing her syndesmosis and she's gone on to do well. Second case I had was a 39-year-old female with chronic left ankle instability symptoms after sliding into second base playing softball. And so the image on the far right, on the far left of the screen, is that arthroscopic drive-thru sign on the syndesmosis where you can get the camera pretty far up the Thanks, Greg, so we're going to open it up to discussion, some remarkably transformative talks and definitely prompt some thought. Anybody in the audience have any questions? I have a whole host of questions and I'm more of a traditional guy and I think that there's probably a lot of people like myself in the audience that feel that their arthroscopic skills are reasonable but they haven't pushed them like you guys have. I guess a couple of questions for both Steve and Andrea for people like myself. Number one, who is the described optimal patient to get started on with either a subtalar fusion or an ankle fusion? Number two, from a technical point of view, what are the two or three most likely problematic issues that we will face when we first start out embarking on this and how do you mitigate those two or three difficulties? I'll go first. From the subtalar point of view, the ideal patient is going to be the simple post-traumatic or idiopathic arthritis that's non-deformed. Unlike Andrea, I'd say that severe deformity of the subtalar joint is sort of higher level arthroscopy. You certainly want non-deformed that you're just going to fuse in situ so that you're only going to potentially address the posterior fascia. That's going to be the simplest case. In terms of the technical issues, I think the biggest one is the fact that you're arthroscoping a relatively small space. Initially with two portals that are quite close together if you use the lateral approach and it's just the technical ability to keep a good view and to know where you are within the subtalar joint. Unfortunately, that just comes with practice. As one of my co-presenters suggested, the more you do, the better you'll get. At least with the subtalar joint, it's reasonable to do your sinus tarsi portals in such a way that if you're failing, if it's taking too long, you don't think you're getting a good view, it's no big deal to open it to a mini sinus tarsi standard subtalar approach. There's nothing lost, nothing ventured, nothing gained basically. I'd have to agree actually also with that in the sense that if you're starting doing arthroscopic ankle fusion, I would start with the non-deformed cases first just to get a bit facile with it. I would also start with the more elderly patients that there's less chance of having issues with malunion or that causing a problem down the road. When you're in the OR and you're starting to do this initially, you want to make sure that you have everything available, that you can actually change to an open approach if you need. You want to make sure that you have fluoroscopy available so you know where you are and what you're doing and how you're preparing it. You want to have an array of items that might help you with distraction if you need. I don't tend to use traction. I just joystick with my scope. Same thing when I enter the subtalar joint. I just use a trocar and kind of jam it in and work from there. But it's often easier when you're first starting to actually have the ability to have traction available. So you can use either any kind of frames that you like using, a gall distractor or a spider. I like a spider if I'm going to do that, specifically some of my pilon fractures. So I think that's really good to have. And then have the ability to use an array of screws, having multiple screws available, fully threaded, partially threaded, all these things available and the chance that you can actually convert if you need to convert. And then when you get a little bit more used to it, then what you do is you start doing those deformities that are just underneath that 15-degree mark. And you have to decide which deformities you want to do. The plaintivologist patients are a little bit more mobile. So you're going to start with them. They're a little bit more mobile. They tend to mobilize a little bit easier. So you're just for those guys doing a simple lateral release and then starting to drive everything medially. The cave of errors patients can be a bit more difficult because they're a bit more rigid. And these are the ones that you really want to make sure that you get used to the techniques so you have fluoro to identify where you are, to make sure that you're correctly posterior transient in the patient, that you're getting good positioning of the talus under the mortis, that you're not in equinus, which can happen. And you want to make sure that you have bolsters available so you can actually drive the construct posterior. So I think for me that was the progression. Like I started with simple non-deformed cases in more elderly than simple non-deformed in the younger and then moved on to doing more valgus and moved on to the more difficult varus ones. But I think the best people to do this in is in the people that you, that just can't lose anything from it. Like the horrible diabetics or the people with bad soft tissue envelopes. They're going to be happy that you've tried something. And those people really appreciate it. I noticed that it seemed like both of you don't use distraction. Is that correct? For the subtalar joint, definitely not. I don't think it helps. As Andrea says, the trocar into one of the portals with an assistant can distract the joint much better than non-invasive traction. With the ankles, I do have it available generally. Often I find it easier to start with. But once you've got going and done the anterior part of the joints, it's not actually necessary. You're creating the joint space by your debridement. You're taking out at least five, six millimeters divided between the two sides of the joints. And it creates a massive space. So as long as you work systematically from the front backwards and create the space rather than trying to do everything, I often find it's easy. People coming new to it will often try and focus on doing all of the talus or all of one side. But actually, you need to flip around and do top and bottom and work your way back, whichever joint, subtalar or ankle. But the attraction is not essential for either technique, I don't think. Same thing, I do top and bottom. When I'm approaching, I do the same thing with top and bottom, both for subtalar and for the ankle joint. The subtalar joint, also the one thing I look for is that, you know, if they're not deformed, I like doing it from the posterior approach. If they have someone who is in varus, I like going laterally because that allows you to burn more laterally and correct the alignment. But, you know, one thing that's nice to have is just a strap so you can attach this to your body if you need. I don't tend to use it. The time I actually do use the traction is if I'm doing like a pilon or I'm really focusing on the distal tibia or an OCL of the distal tibia. Then, Andrea, the study that you guys did comparing arthroscopic ankle fusion to open, it was seen that there was an inherent selection bias, that the people that were done open were harder cases. Is that true? So, in the non-deformed case where we actually looked at arthroscopic versus open versus total ankle, they were actually nicely and evenly distributed. Basically, it was just type one non-deformed ankle arthritis and very similar age ranges, very similar sex ranges in terms of the groups, a little bit more predisposition towards having females in total ankle replacement, older, obviously, in total ankle replacement. In the deformed group, the difference was actually the distal tibial angulation, not the tibial tailor angulation, but distal tibia. In those cases, the group tended to do more open fusions. Great. I don't know which one of you guys was first. Go ahead. Thank you all for your talks today. My question, I'm Casey Powell from Ventura. For Dr. Heppel, when you're talking about the double and triple arthrodesis with the scope, for the tailored avicular joint, I might have missed, are you doing anything medially? Are you really approaching that whole joint from the lateral side, or are you augmenting that? Generally, all from the lateral side. The vision is achieved by the scope from the lateral side in the sinus tarsae. As I suggested, there's a buffet of different portals you can use, and depending on how easy the access is, how concave the joint is, how stiff the joint is, you may have to use a progressively more medial dorsal portal. There is a true medial portal described by Louis, but in the position I do them, it's technically difficult to use that. At the worst, I would use dorsal medial. Gotcha. Thank you. One last quick question. Quick question. Todd Kyle from Scottsdale, Arizona. Thanks very much for your talks. Question about distraction or not distraction, whether you use it or not. How do you remove the cartilage and the subchondral bone from curved surfaces on both sides of these joints using a straight scope and a straight burr or a straight shaver? In other words, do you just say after about half to two-thirds of it that that's enough to get a successful fusion? Or how do you get over the hump to debride that cartilage and subchondral bone from both surfaces on the opposite side? The tibia is usually fairly easy. The talus is where it becomes a little bit more tricky. And usually there, usually I end up just hyper plantar flexing to get to the back part. But sometimes you need to get – that's why I have an array of curved curettes. So you have curved curettes, and sometimes you need to use an accessory posterior medial portal. So then what I'll do is I'll do an accessory posterior medial portal and enter that way and just do some preparation from the posterior medial portal. There's a power rasp that's a little curved as well that you can use that can help get in the back. We can't afford those in Canada. Thanks so much for a great session. Thank you.

arthroscopy

ankle injuries

syndesmosis

patient selection

arthroscopic techniques

technical challenges

outcomes

post-traumatic arthritis

research