CME OnDemand: Managing Complex Ankle Arthritis and Deformity with Total Ankle Arthroplasty-Foot & Ankle Focus: Managing Complex Ankle Arthritis and Deformity with Total Ankle Arthroplasty

Foot & Ankle Focus: Managing Complex Ankle Arthritis and Deformity with Total Ankle Arthroplasty

Video Transcription

On behalf of AOFAS, I want to welcome you to tonight's program, Managing Complex Ankle Arthritis and Deformity with Total Ankle Anthroplasty.  It will be moderated by Dr. Mark Easley. Joining him are Dr. Samuel Adams, James Nunley, James D'Orio, Karl Schweitzer, Konstantin Dimetricopoulos, and Cesar Netto.  You can find their full biographies and disclosures in the program document posted in the chat box and in the AOFAS On Demand Education Center.  2023 webinars are provided free to AOFAS members and orthopedic residents, fellows, and medical students with funding from the Orthopedic Foot and Ankle Foundation, supported  by a major grant from Stryker and additional funding from Anthrax.  To support education programs like this, make a donation to the foundation on our website or by texting GIVE AOFAS to 41444.  I'd like to run through a few housekeeping items before we kick off the presentations. For technical difficulties, please try closing your browser and logging back in the same  way you did the first time. Candidate physician attendees may earn one hour of AMA PRA Category 1 CME credit by completing  the evaluation and CME claim form at the end of the webinar. You can find the link to claim CME in the chat tab, and we will follow up with an email  following the conclusion of this broadcast. This webinar is being recorded and will be available for on-demand viewing on the On  Demand Education Center content library in approximately 24 hours. We encourage you to ask questions during the presentations.  To send your question to the faculty, click on the Q&A tab on your navigation bar. If we cannot get to your question during the live broadcast, the faculty will reach out  to you following the broadcast to respond. Finally, please visit our website to register for upcoming events, including our next Foot  and Ankle Focus webinar on Wednesday, June 28, and our AOFAS Annual Meeting for 2023 in Louisville, Kentucky. I now turn the program over to Dr. Easley to begin. Thank you.  Lucas, thanks a lot. Great introduction. I'm really excited about this. So we've got a great faculty here.  Yes, there's a little bias there maybe, but I think we'll have a good time sharing what we know.  Most important to me is that we have a chance, so I see there are a lot of participants already on the call, and so we want you to ask your questions.  So in the Q&A section, please throw your questions in. I recognize you can't do them live with voice, but put them in and we'll make sure we get  to all the questions as best as possible. I've split it up a bit so that we will have presenters and then someone who will lead  the discussion, and the goal is that we will get to a lot of interesting topics that I think pertain to this session, which would be valgus ankle, varus ankle.  We'll also talk about different approaches, use of weight-bearing CT, some complex topics such as maybe even ankle fusion takedown and conversion to an ankle replacement, and then  revision cases and even have topics that address 3D printing in this complex deformity session.  So without further ado, I'm going to turn this over to Jim Nunley, who is going to present our first case and our first topic. Jim.  Thank you, Mark. So this first case is a 61-year-old female who had a triple arthrodesis for a long-standing pes planus. That surgery was done in October 21.  She now presented to us complaining that her foot had dropped more since her surgery. No significant medical history. Never smoked in a BMI of 18.  This is her standing x-ray as she presented with the ankle. And there's her foot x-rays. So Constantine, what do you think was the reason why this triple seemed to fail?  Well, I mean, it looks like it healed. So at least I got the bones to heal, but certainly the ankle has failed in valgus. And I think hind foot alignment is important.  Getting the heel underneath the tibia is important. Getting the first ray stable. So you can see the patient has a helix valgus deformity, and maybe with some subluxation  of the first partial joint there on the AP. So the combination of the heel being well aligned, the first ray being down, those are the two important factors.  When they do the triple arthrodesis, they didn't recognize that it was a stage four and they didn't pin the ankle joint in the corrected position.  So then they get a situation that looks like this. But be that as it may, this was the CT scan. And as you correctly showed, the fusion is solid. There's a 3D reconstruction.  So what is your thought process on how to handle this? By the way, I should point out that there are some other extenuating circumstances here.  As you can see, this is her standing alignment. She's had bilateral total knees, the left side got infected. And after multiple debridements, she's an amputee.  So we really need to get this ankle done correctly. This is the appearance in the operating room of the foot as the tourniquet gets put on.  So to make things a little quicker, the first thing we do is a ligament release until we can get the talus directly underlying the weight-bearing axis of the tibia.  And then we pin that in position. As you can see, the screw is taken out of the subtalar joint. And in this situation, we're planning to do a resurfacing ankle replacement.  So we use our standard alignment jig to get the anterior slope and the resection. And you'll notice that we've under resected so as to try to maintain some more ligamentous  stability.  Place our tailor component, and we have a well-aligned… Jim, could you say that one more time? I think it's important.  What do you mean you under resected to get better ligamentous stability? So in these patients, many times they have global ankle instability.  And if you do the standard resection, which with this particular manufacturer requires a 7-millimeter resection, I'm not sure if you can see my pointer, this would be the  area where the resection is, and this should be at the level of the plafond. So if you undercut it, you'll maintain more tension in the ligaments, and many times you  won't need to do a ligament reconstruction at the end of the surgery. Okay, thanks. So the tailor component, and there we have what seems to be a well-aligned ankle joint.  But we still have the problem of, as Constantine said, the hind foot is still in valgus. So now we have to do a medial calc slide, and then we have the problem of the forefoot.  And the forefoot, as you can see from the picture above, is massively supinated, and you have to get a stable medial column, and you have to get that forefoot in the corrected  position. So we have to do an osteotomy through the midfoot and use some type of minimal fixation so that we can get some maximum stability.  And the interesting thing with this case, and you can see as we prepare the joints there to do the midfoot fusion, is that after we finish this, we still have complete deltoid  insufficiency. And you can see with the photograph here, we're looking inside the prosthesis, the talus, and the deltoid is completely incompetent.  So at this point, we need to do something to develop competence. And so what we've done here is we have exposed, and we're going to use the local tissue as  well as some fiber tape to reconstruct a deltoid ligament. So that's the thing that this will be as we insert the device to augment our repair of the soft tissues with the anchors.  And here we are tensioning. And this will be the final appearance when the surgery is complete. And you can see the anchors in the medial mellitus and the stable ankle.  So medial deltoid insufficiency in total ankles, I think is a very rare phenomenon. We almost never have to do a reconstruction.  This is one of the few cases where we actually had to do a reconstruction, not of the lateral ligaments, which we have to do at least 15% of the time, but of the medial deltoid.  So Constantine, I know you are at an institution where one of your partners has written about deltoid reconstruction.  Do you want to talk about what your thoughts are on when this needs to be done in total ankle replacement? Well, sure.  Do you want me to show a couple of cases, and I'll talk a little bit about that? Or do you have other slides to show? No, that's it. I'll stop sharing. You can show your case.  Great. So to that point, one thing I'll say is when Mark first asked me to do this talk, he said  my title was Things I Learned After Fellowship. And the first thing I learned after fellowship was that I'm not as good as the people that I did fellowship with.  And so here's a case of a patient that has a valgus ankle and has a valgus hind foot. And one thing you'll notice, a little different from the case that you showed, Dr. Nolley,  is that the ankle deformity is not so bad, but the foot deformity is almost worse. And if you look at the lateral, you'll see here that the lateral, also the foot's quite flat.  And people always say, well, can you do it at once? Can you do it staged? And so one thing I learned early on was maybe you can do it as one surgery, but maybe I  need to take two surgeries to do it. And the question is, which do you start with?  And I always say, well, you start with the worst deformity and then you work your way to the lesser deformity.  So here you can see an intraoperative image where I've put a cement spacer on the lateral tibia-tailor joint to correct the tailor tilt.  And I've done a midfoot osteotomy as well as a calcaneal osteotomy. So similar to what you did after the replacement, well, I've done it after temporarily holding  the ankle straight. You can see there the medializing calcaneal osteotomy.  And then once that heals at about six months, then I can go back and I can do my replacement.  Now, I use a different kind of replacement just to get a little bit more stability given the arthrodesis in the hind foot.  And in this case, I did not have to do anything to the deltoid. You can see here the ankle looks quite well aligned.  And you can see here the before lateral and then the after lateral, but sometimes I'm not always correct. Here's another case of a severe flat foot deformity.  And as you can see, you talked about that ligamentous instability in the ankle, and you can see how severely unstable this ankle is.  The talus is internally rotated and fallen out of the ankle mortis. There's both lateral and medial ankle instability and a very severe flat foot deformity.  Actually, one of my partners did this case initially, they did an arthrodesis of the hind foot and they stabilized the medial column.  But as you can imagine, this didn't go too well. The talonevicular joint was a non-union, the ankle arthritis progressed.  You can see there one of the screws are broken across the TN joint. So I revised the talonevicular arthrodesis.  I did the total ankle, I minimized my bone cut, I thought I did a good job. And then here's my x-ray at six months. And what I failed to realize were two things.  The first is I didn't correct the hind foot alignment enough. And in this case, well, maybe I did need to do some deltoid augmentation.  And so then we took this patient back to the OR and I did a deltoid reconstruction. Now, this is the semitendinosus allograft reconstruction of the deltoid and a medializing  calcaneal osteotomy. And thankfully, this patient now is many years postoperatively and doing well.  So I learned the hard way that sometimes to your point, the deltoid does need to be reconstructed and it's okay. If you notice it afterwards, go ahead and take care of it.  Don't leave them in valgus. So let me stop both of you there. So Dr. Shah, who we know from India, has a question. And I think Constantine, you answered it.  But Jim, you suggested a fiber, well, you did an anatomic reconstruction of the deltoid and then fiber tape. And Constantine, in this case, you decided to do a hamstring allograft.  So Dr. Shah was asking, why not use a hamstring graft for the deltoid? How do you guys decide? Is there a time one's better than the other? Does it not matter?  Or is there just more information still needed? Well, I think of the, I'm sorry. I think of the, anytime you use a suture reconstruction, it's either on or it's off.  And that's not really how ligaments work. It can be a nice backstop if you're worried that you want to protect the repair and then use a suture augmentation to protect your repair.  But if you're really worried that there's nothing there, I think something that has some elasticity to it is preferable. And so I use this allograft.  Now to your point, Mark, there's no data to really say one is better than the other.  So I don't know that anyone can say they're right. I think we all just have our opinions and we're trying to sort this out.  When you use an allograft on the lateral ligaments, we always have ligaments there. They're always stretched out. And in this case, the deltoid was there, it's stretched out.  So we've done hundreds of lateral ligaments with a Brostrom and sometimes using an augmentation. And so why not use the local material and use an augmentation?  And it just didn't feel like, first of all, drilling up into that medial malleolus was likely to be able to accommodate a massive tendon allograft. Yeah, so that's good.  And I think that there have been good examples. I think Jonathan Delane has done a great job with this. Steve Haddad has some great experience with it.  I'm always impressed with what can be done. I do think you have, I think Constantine, you emphasize and Jim, you did too, you have to get a good stable foundation.  If the foundation is not solid and you just try to rebuild the ligaments and that should fail, you'd have to have a good platform on which that rests.  But one question real quick before we finish your session, which has been great. When you do this and a ligament reconstruction like this, do you drill a hole into the talus  as well? And if so, are you worried about avascular necrosis of the talus when you've done hindfoot surgery?  Or if you've done ankle surgery and now you're going to do another medial surgery, could you compromise the blood supply or are there some tricks to doing that safely?  Well, in our case, there was no subtalar fusion. So we hadn't violated the sustentacular, we hadn't done the sinus tarsae.  We'd done a talonevicular fusion, but there had already been a previous fusion there. So I didn't worry so much about it, but maybe I should have. I don't honestly know.  That's a good thought. Yeah, interestingly, Mark, I think that when the hindfoot is fused, you're more likely to run into trouble with the deltoid, right?  It's a bigger moment arm on the deltoid. When the subtalar joint and the talonevicular joint are not fused, then there's a little bit more forgiveness.  So obviously when they're fused, you don't have to worry about that as much, but certainly you could do your deltoid from the medial malleolus to the sustentaculum and then send  a limb over to the navicular as well and try to avoid the talus. I think for that reason also, I really worry about using any augmentation device or allograft  for lateral ligaments and total ankles because the talus has already gotten a good beating. You don't want to make more holes in the bone.  So I really try to avoid putting tunnels in the talus. In previous arthrodesis, it maybe matters a little bit less. Well, this has been a great session.  We have more to learn, but thanks for sharing it. And the one thing we didn't discuss in detail, but you obviously see there are ways to put  the ankle in first and work proximal distal or building the foot together first and then coming back and doing the ankle.  But at this point, I'm going to turn it over to Jim DiOrio, who's going to share a case  with us and Carl Schweitzer will lead our discussion. Jim? Okay. Okay, guys. Thanks very much. So this will be on varus ankle.  So my conflict of interest. So it's important to examine the patient first. And if they come in with a cast on, you want to make sure you take the cast off before  you check sensitivities, but you want to rule out a neuropathic ankle. And no matter how enthusiastic you get, you got to remember that not everybody shares  your enthusiasm, particularly in your home front. Okay. So here's the case of a 72-year-old guy. He's the owner of a Chick-fil-A.  And when he's asked how many sprains has he had, he says, too many to count. So it's probably about 12 to 20. And he's got a nice small deformity there, 47 degrees of varus.  Now when I started doing total ankles, somebody said, you can't do more than 10. And then five to six years later, that went up to 20.  So now I'm of the firm belief that it doesn't matter how much deformity you have, you just have to be able to correct it.  And I would venture to say that of all the people in the audience, at least 100% of you would say that this patient is going to require a lateral ligament reconstruction.  And so we'll see. You can see that the hind foot is insignificant varus. But I would contend that the majority of this deformity is at the ankle, not the subtalar  joint, and not within the calcaneus itself. Subtalar joint looks reasonably good, slight amount of cavus.  And he gets a standard total ankle, and much to my surprise, as I suspect it's going to  be your case too, no lateral ligament reconstruction was required. As Jim just mentioned, the lateral ligaments are always there.  And so if you can extend this out enough, then you can balance the ankle. And so while I was very surprised that we didn't require a lateral ligament reconstruction,  I certainly wasn't going to do it if we didn't need it. And you can see that the medial medial is somewhat thin, so I don't hesitate to put  in a prophylactic screw on that before I break it. Now doing that deltoid release, I'm surprised there are probably people in the audience who have never done that.  It was the early 2000 when I went over to France, and Michel Bonin showed me this complete release of the deltoid ligament.  Herefore we had always protected it, but here he just took the whole thing off. And so this is us taking that off.  And then when I get to the back there, I'll take a periosteal elevator and push the soft tissue away so that I don't cut the posterior tibial tendon. And that's how you do it.  And you can see how far up I went for that deltoid release. And here's the stress on the ankle. Now you can see on the left, the ligament has been released, but no stress.  And then when you go to open it up, you go, oh my gosh, look at that. We're going to be able to balance this ankle. And it's always exciting to do that. So, I've  probably done this no less than 300 times, and I have not created any instability on the deltoid ligament. Now, in terms of support for doing this kind of ankle, this particular  article said, the total ankle replacement improves clinical and functional outcomes, independent of the preoperative tibial tear alignment. So, that means that it doesn't matter how  much varus or valgus you have, as long as you can restore it to neutral at the time of the arthroplasty, they can do well.  And here's our patient now walking on his way to the Chick-fil-A. And I always ask my patients to do a little something extra. And this guy had a lot extra. So, in this  particular article, talk to the impact of preoperative varus on ankle replacement survival. And again, it did not matter. Only  the postoperative alignment and stability emerged as survival factors, not preoperative degree of varus. Now, this particular  article talked about doing a Dwyer's osteotomy with lateral displacement of the calcaneus. I have found it not necessary to  do these. And so, if I have to do them or think I have to do them, then what I'm thinking is that I did do enough correction  at the actual ankle. So, I rarely have to do a calcaneal osteotomy in combination with a varus deformity. The deltoid ligament release, very common, the anterior talofibular  ligament, the calcaneal fibular ligament reconstruction, and not so much with suture tape, I would do a standard Brostrom ligament reconstruction. And that's starting to work very  well. And then releasing the posterior tibial tendon, also not frequently necessary. And if I have to do that, then I know  Doetts in Europe will frequently transfer the posterior tibial tendon to the lateral cuneiform and to balance the ankle. And  then one note that wasn't in the article, I won't hesitate to do a dorsiflexion osteotomy of the first metatarsal for a four-foot  driven hindfoot varus. And I think that's very important. So, and we talked about two-stage, I have done about 1600 total  ankles, I actually I don't think I've done a two-stage ankle replacement. I feel some empathy for the patient having had  multiple surgeries myself. And so I think most of these can be corrected at one time, the exception being infection. So I'm not sure you have to do it in two-stage, but probably  nothing wrong with doing that. It just that I have a lot of empathy for the patient and would not want that myself, nor do I have to do a subtalar arthrodesis very frequently. So  these are some things that you learn with personal experience.  So that's it. Thank you, Carl, you got some comments? Yeah, certainly do. Yeah, I'm sure. Let me ask you a question while I'm pulling up a case to kind of poke the bear. So talk  to me about your pre-op workup. What additional, we saw weight-bearing foot and ankle x-rays, you know, just in general to share with the audience. What else are you  getting? Full-length limb views, weight-bearing CT, can you talk about your workup?  Yeah, those are good questions. So we haven't got full-length views routinely. I, quite frankly, have never experienced an incidence where I said, Oh, I should have got full-length  views. So I don't routinely do that. There's nothing wrong with getting a CT scan here and checking out how much subtalar  arthritis you have. It just seemed like he wasn't having any pain there. And I had enough deformity to work with. There's nothing wrong with coming back at a later time and doing a  subtalar arthrodesis. Most of them aren't going to need it. So that's not always necessary.  On these bad bears cases, have you ever checked out of interest, like a post-op limb length view and ever been happy or disappointed?  I haven't checked it. And most of them turn out relatively well, and without recurrent deformity.  Can you talk at all about your cut on your tibia on these really bad bears? It looked like maybe you cut a little bit of valgus into it.  Yeah, no, that's a good observation on your part. What you don't want to do is to leave them in some varus deformity. So  if I air, then I want to air and I think this one is one degree of valgus. So just a slight amount of valgus, but you'll see  so many people put their ankles in in varus. And the reason is, because they don't look all the way up the tibia, not necessarily because they don't have a full film, but they will  just look at the bottom six inches, and they'll put that ankle in correctly. So the next time you're hearing talks on  ankle replacement, look how many are in varus. So it's very, very important to try to get that in a little valgus, I think.  Perfect. This is a case I shown it in ICL previously, but I'd be interested in your thoughts on how you might approach it. So  this is kind of your standard 66 year old male healthy varus ankle, varus foot, perineals work, but a little bit weak on  the brevis, a tight Achilles, and some adduction deformity to the foot in addition to the cavus. So again, this is an incongruent varus deformity. Do you approach it differently if  it's congruent versus, you know, where you have erosion of the distal tibia, medially versus the incongruent? Are you thinking about anything differently that you might need?  Oh, that's another good point. And I know Roger Mann brought that up and, and he made a big deal out of that. I don't, I don't feel like that's too important. What I do look for  here is you can see there's no invagination of the medial talus into the tibia. And so that always leads me to believe that I'm more likely to do a lateral ligament reconstruction  that is all the opening is occurring on the lateral side, and you don't have invagination of the talus on the tibia, which would reduce the amount of shortening you might need to do  on the lateral side. That's a great point. So here's some of the weight bearing views we got. Here's the CT. Can you talk a little bit about how  to get this angle to neutral in the OR? How do you de-rotate the talus? Any tips for the audience and things you might be looking for in the gutters, medially or laterally?  Well, it's already been mentioned, you want to make sure that you don't take away too much bone. Okay. And so in this instance, you've got a non-union of it looks like an old medial  malleolar fracture. Nothing wrong in this case, with taking that out, and then imbricating the deltoid on the medial side  to make sure that's stout. But I think that this can be done. And it's always surprising at how you can get that ankle in. And then if it opens up laterally, then you're going to  have to go do that lateral ligament reconstruction.  Perfect. I think you addressed a lot of these questions. So I'm just going to move forward quickly here. I think you had mentioned that you really tend to use a less of a resection  implant system for your total ankle. When do you ever feel the need to use something with more robust tibial fixation? Is there a need or?  I think a patient's bone quality is the main factor. So if I have somebody who's heavy and osteoporotic, then there's nothing wrong with going to a stemmed implant. But for this  guy who was otherwise robust, active, very strong bone, I thought I could get it and I did.  So here on the initial approach after an Achilles lengthening harvested his posterior tib and planned to transfer it to his  peroneals. They were functional, but the brevis was a little bit weak. I thought that that was important. How often do you find  that you're doing something to the medial midfoot releasing the TN spring ligament in either Z lengthening or transferring the posterior tib?  Not often, but this is a good point that you're bringing up. And I had mentioned transferring the posterior tib, you're going  to get some of these people in who have Charcot-Marie-Tooth disease. And in those patients, I think that's critical.  Perfect. I tend to look at the AP of the foot and see how much medial peritailor subluxation there is and identify if it's a  posterior tib overpool and then try to make a decision on transfer or Z lengthening. I think it's also an important point to get the impinging osteophytes out of the lateral  gutter, decompress medially, obviously all those exostoses and spurs to decompress the deltoid. But also if you don't  remove the blocking loose bodies and osteophytes laterally, that can prevent derotation of your talus too.  Let me stop you for one second. So a question just came in about that exact point. When you, as Jim Nunley likes to put it, when  you get the rug out of the door so that you can actually get the reduction, do you do that through the same anterior approach? Or do you make a separate lateral approach to  clear the lateral gutter?  I generally do it through the anterior approach. You know, if there's any struggle, and eventually I know I'm going to need to go laterally for a ligament reconstruction, then it  could also be dealt with at that point. But in the case I'm showing, I would have to get it to neutral before I'd be comfortable moving forward with cuts on the total ankle.  Perfect. So you do it through the same approach. Good. Yeah. Yeah, I just want to make sure that question gets answered. Go ahead.  Perfect. And then pinning, I liked it on this guy. He's tall, large guy, I thought it might be better for an intramedullary  based system here. But again, I think to your point, I think you could, you know, perhaps consider use of a less resection implant, or resurfacing implant. Again, also  pinning it in distraction, I found that to be really helpful to minimize your bone resection. And that helps minimize your  poly thickness and ultimately helps with stability. Just move forward here. So here, I've got the metal in poly trial, and I'm stressing it. What's your threshold for accepting any  amount of instability, particularly lateral? And what's your threshold to do a brostrom? One millimeter.  Of tilt? Yeah, one millimeter of opening. Okay. So here you have about two and a half. So I would not accept that.  Perfect. Yeah, we did not accept that. And then here, I'm just kind of finalizing the soft tissue tensioning of the transfer, and also doing a longest to brevis transfer. And  then really assessing this isn't necessarily a four foot driven hindfoot varus, but I felt like it was more of a residual  hindfoot varus. And so corrected that. And at that point, I didn't feel like I needed any type of correction to the metatarsal.  Looks good.  Yeah, I mean, it still looks perhaps a little bit of varus on the post-op, but the limb length, or I'm sorry, the full length views and the heel alignment view suggests he's to  at least neutral. So yeah, that's a great case, and appreciate you sharing it. Good discussion. And with that said, we have to move on to the  next session. So I'm going to have you stop sharing your screen and, and turn it over to Cesar. Cesar, can you enlighten  us how to go through the window instead of coming through the front door and doing a total ankle replacement?  There you go. Can you guys see it?  Yep, see it.  Okay. Well, thanks for having me. The real reason why he invited me just for me to be the sacrifice lamb because we have all this Duke trained people here and I'm not Duke trained  even though I joined Duke now. And I'm the only one doing lateral. So you see how this goes. But this is a 63 year old  female patient. She's diabetic type one. She's well controlled. She has no neuropathy. And she had a fracture about a year ago.  She was treated in an outside facility. She had a trimolecular fracture. This is the way they fix her. So she's now with  end-stage ankle arthritis. Pain focus on the ankle, of course. And we can see in his x-ray, Sam, I'm going to ask you a question soon. But these articular valgus and these bone  loss on the lateral side, you see there's a there's a diva there. There's the missing bone stock there. These are the  weight-bearing CT images. I like to say if you're if you're lazy, and you don't like to take pictures, you can use your weight-bearing CT images to get your clinical pictures. And  these is the weight-bearing CT with that bone loss on the lateral side and the articular valgus that I'll tell you, Sam, that I measure. It was 16, a medial distal tibial angle. So  before I show what I did here, Sam, and I show you some more weight-bearing CT stuff, what would you do? She wants a total  ankle. And she was denied it by other providers because of her diabetes type 1.  Yeah, well, I think you don't have to show us what you did, because I think we all know what you did. But for me, I mean, I think it's a total ankle through an anterior approach. If  I look back at those images, there might be some syndesmosis widening. And some of these I'll end up fixing or trying to fuse  the syndesmosis or at least put screws across to really help bring that fibula over. But I'd probably tackle this through an anterior approach.  What do you worry about that? I haven't been 1500 like Dr. Diario. So I was worried about this because I'll show you why.  But I was worried that not just the articular valgus, but also that bone loss on the lateral side, when I was coming from the  side, I was worried that I would have to cut too much bone on the medial side to align that cut. So would you worry about that? Or you  Yeah, I mean, you could argue to do a tibial osteotomy in addition to your total ankle and help offload that and avoid taking too much bone there where that bone loss is.  Yeah, that was the discussion here. So and a lot of excitement for the lateral approach that you can correct big deformities,  right? That's one of the selling points of getting this jig and taking more time to do the same thing that you can potentially  do from the front. Again, that bone loss there. So I called Dr. Sean and said, What do I do? He said, you can do it, you don't  have to do a supermolecular osteotomy. And of course, I did not follow his instructions, because I was too worried about that. So this is the that bone loss there. And I was worried  that when I would bring the melee device here when it was burning, that it would have to take too much bone on the on the medial side to be able to correct for that deformity. So  you guys know that I do foot and ankle set. So actually, this patient, even though she had a bad valve on the ankle, you see  foot and ankle set is 5.5. That is just a little bit more than the normal that goes up to 5.2. She still has a valve or the foot  is lying lateral to the center of the ankle joint. And the way she's compensating for that is that she does have some compensation in various of the foot. You can see the elevated  forefoot arch angle to get her foot plantigrade on the forefoot there. So there's some stuff that we're doing, we're actually  working on writing a manuscript about this, just a better way with distance mapping, you can see the joint a little bit better in terms of the arthritis. For this case, you  don't really need it. But for some more complex and some minor,  milder cases, it's an interesting thing. You can see that the medial side, there's no distance maps on the medial side because of the valve. So the tail is not really articulating  with the medial now. And you can see the stress on the lateral gutter because of this increase in articular valve. So I did decide to go for the for the supramalleolus. I did my  calculation. There's no time to talk about these today. This is what I wanted, right? I wanted to bring a better aligned ankle  so I wouldn't have to remove that much bone on the medial side. So here we go. So I plan I decided to do all the same time maybe I should have not. I stressed a lot to do this. And  then plan my medial closing wedge, provisional fixing and medial plate. And then once I had that, I went laterally did my lateral approach and much better. You can you come from  the window where you can see the joint much better. And then you bring bring the big frame that I know people get scared about.  Measure your size, align the talus with the frame, then you see that there's some inter subluxation of the talus, my tail is now fixed. Now that my ankle is in a better position  with the SMO, I aligned the cut of the tibia neutral because I corrected the valve is distally. Then I correct my sagittal  balance there and then fix my tibia, do my cuts, put my trials for the radio cutting guides, fix my fibula. And then it is  and I was afraid to remove my wire in the end because I like the wire there was kind of hitting the medial med with my burr the entire time. So once you're done with diabetes type  one, you start praying, right? As well, because again, I don't have 1500 cases. This is a patient with six months. This is  a patient with 18 months, she was she's she's very happy. With a weight bearing CT, you can do some magic and look to your  implants. If you want to see asymmetric position and things like that. You can look at these 3D. This is the weight bearing CT view and pretty better alignment, she was able to heal  that super well. And if you look to her foot and ankle set, now I put her into a little bit of varus. So I decided not to do  anything intraoperatively. I agree with what you said. For the varus, put in a little bit of valgus in this case, I didn't  want a valgus so I prefer the varus for minus 2.06. And then just to base a little bit on the literature, there's not a lot but a new group and Dr. Hintermann published their  algorithm. They considered a supramolecular if they have more than 10 degrees of coronal plane malalignment. They published  this with 15 patients where they did the SMO before the total ankle, 16 patients where they did it simultaneously and 18 patients that they did to correct the malaligned total  ankle and the results were worse when you do after. So the best results actually were for the stage rather than doing both at  the same time. But it's a retrospective study, not a lot of strong data there. And then we did publish these actually with Francois Lins, my friend from France, where we looked  into cysts and residual malalignment of total ankles. And what we found was if you have a residual varus, you have more cysts on the medial side, it makes sense. If you have more  valgus, you have more cysts on the lateral side. And then we found that if there's kind of a danger and a safe zone, if you're in between minus three to plus five with your foot and  ankle set, that is protective. So the likelihood of a cyst or problem with your total ankle goes down. So I was minus 2.06.  So I was kind of in the safe zone. That's why I decided not to do anything to realign the hind foot. Just to highlight some ongoing work because we were supposed to talk a little  bit of total ankle replacement. We're working on bringing the hip and the knee into the game here. Now that the weight variance CT allows you to see more approximately, and we're  trying to bring not just the foot and ankle set, but the hip knee foot offset where we're looking where is the ankle, where is the knee, and where is the hip in relation to your  tripod. So this it's totally like you have to relearn stuff, you have to reconsider your prior understanding when you bring to the 3D. So we're still trying to figure out how to do  the interpretation of that. But we have some data and hopefully we're going to be bringing that soon. And we also just got  accepted for anchor ties, not for the total ankle, but we're starting to play with houndstooth units. And I know Dr. Dimitra Coppola has also played with houndstooth units  in a different way before. But as you can see here, and it's difficult to explain with not enough time, but when you do have varus or valgus, your bone density gets, as shown in the  literature before, in a neutral patient, you're kind of a distribution of 50% of bone density for one side and the other is kind of in the midline. When you have varus, that line  is pushed towards the medial side. And when you have valgus, that line is pushed towards the lateral side. I think that will  implicate decision making of where to put screws, where to put implants, where to sit your total ankle implants, and also  when and how to correct your overall alignment. And this was true for the tibia and the talus. So I think for planning, sky's the limit. So Sam, sacrifice lamb, go for it.  Yeah. No, no, that was excellent, Cesar. So I think, you know, for most people on the call, they're probably a lot more familiar with an anterior approach. And we all have our  opinions on which deformity is easier to fix for, whether it's a varus or valgus. But coming from the lateral or coming from  the window, which do you feel is easier to fix, a varus or a valgus ankle deformity?  Yeah, I think both. When you have severe, I think both are very tough. They're both challenging. The varus, usually because we're coming from the side, if I mean, Carl showed the  cleaning of the medial gutter, right? so if you have a bad varus with the lateral approach your threshold to open immediately  should be very small sometimes you have bad osteophytes on the medial side once you start  distracting the foot to bring it into position you can't really do it and then you start putting a  lot of stress in the medial mal so I started either opening medially or with the frame  you can do a tibia chew cut that is a like a pre-cut where you remove a lot of bone to create  space for you to swing your jig and correct it so my threshold if you have a bad varus to do the  tibia chew cut and or open medially is very small because it makes it easier to get to the next  steps of the total ankle but the bad valves are tough as well I mean this one like I said Dr.  Sean told me you don't need the SMO but I was still worried about because I didn't want to  resect that much bone on the medial side I wanted to preserve the bone stock so I mean maybe he's  not here but I think you would still think that he would do because you can really crank the frame  and correct that but I'm happy that I was able to preserve the bone if she didn't heal or she had a  complication then maybe I would say maybe I should have followed his advice so I'm glad that she  she did well and and obviously in that case you showed you did an SMO but if you weren't how often  are you augmenting the length of the fibula either shortening it or lengthening it to help correct  the deformity after you're done? Very frequently with varus and valgus I mean when you have a varus  you usually have to shorten the people in the end if you have a valve you usually have to  lengthen the people in the end so you that's the beauty one of the beauty of the lateral total  ankle in my opinion because cutting the fibula helps you to correct the deformity without having  to do crazy soft tissue releases and things like that so it's very rare that we do soft tissue  releases because the frame helps you to to bring the ankle into position it's I haven't I don't  remember of all the cases that I scrub with my mentors and at union that they did any deltoid  release with with bad cases of varus and we were able to correct them by pulling traction without  doing any any delta release that's different than cleaning bone right that the tibia to cut would  give you that. And so when you're doing your fibular osteotomy what type of osteotomy are  you doing to help facilitate facilitate shortening or lengthening? Yeah I actually for I just switched  and as you know one of the most common reoperation causes for the lateral approach is the fibular  plate actually brings the reoperation rate super high so I always thought about why not try uh intramedullary device in the fibula for that reason to try to avoid a um a um uh  cardioremoval so when I when I when it's neutral or varus I can cut the fibula transverse and be  fine when it's valgus too bad of a valgus and I need a lengthening then might not be possible  because then you would have to put a intercalary graft or something like that or a piece of the iliac crest or something but I we usually traditionally we do a oblique cut in the  fibula if you're not doing an intramedullary device but I recently changed and I've been very happy with the intramedullary in the fibula for varus and normal alignment.  I'm going to have to stop you guys now that's awesome discussion and it's good wetting our  appetite so maybe sometime we can have another session and have even more discussion but we have  to move on to the next one and Cesar just to be clear you're not the sacrificial lamb we invited  you because we love you. Thank you. All right so let's move on um Constantine um let's have  you share your screen and share your case and then we'll have Jim Nunley make some comments.  Okay um so here's a case of a patient uh whoops sorry about that here's the case of a patient who  had a an ankle arthrodesis procedure and still had pain uh one year later and I would tell you  that the best procedure for an ankle arthrodesis non-union is to do a total ankle replacement so  here you see removing the hardware and uh it's easy to identify the joint oftentimes when you  take the hardware out you can see the ankle move or you can put a freer in there or a cob elevator  and before you know it the ankle's freed up it's easy to identify the joint line and you can proceed  and do a pretty straightforward ankle replacement and you can get pretty good motion particularly  if the arthrodesis procedure hasn't been that long ago and this was relatively recent it was only a year um now here's another case of a patient with rheumatoid arthritis who fused  and this patient seemed to have fused not in the best position and as you can imagine when the  ankle is in Aquinas the load is going to get transferred to the midfoot and this patient has  debilitating telenovicular pain and arthritis and so the question was what do you do do you do a  telenovicular arthrodesis do you do a tibial osteotomy well in this case I did both an ankle  replacement to get the ankle in a plantigrade position as well as a telenovicular arthrodesis to  treat pain so this really brings me to the concept that when you're considering taking an event confusion to replacement your best indications are non-union and malunion  but really your relative indications are adjacent joint arthritis and it's very hard to know the time  to what's the right time to do that and as you can imagine contraindications  exist particularly absent maliali and other contraindications in general to replacement  and the literature does support takedown of ankle arthrodesis to replacement but certainly the results are not so straightforward they're not as good as a primary ankle replacement  and so for those that say well fuse now replace later I would say well that replacement later is  not so good and so it's better I think to replace earlier and we have many more revision options  that you'll hear from Carl and others and so there's been a few papers written on ankle arthrodesis takedown also from the group here and Dr. DiOrio and the Duke faculty 23 patients  with three-year follow-up 87% survivorship but complications can occur a more recent paper  by Chris Coetzee 51 ankles with four-year follow-up he actually had pretty good results only one failure with good range of motion dorsiflexion as well as plantar flexion  all right so Dr. Nunley here's this case and this is a 51 year old woman and she had an ankle arthrodesis many years ago and she healed and she came to me with subtalar joint pain  so what do I do for this woman do I just take the screws out and fuse the subtalar joint  do I try to do a takedown it's a in my opinion it's a relative indication what are your thoughts  on this I can't believe you showed this case because I have this exact case in my office last week a lady that I've used in 2008 in perfect position like this and she now has  subtalar arthritis it's terrible and I've been injecting her subtalar joint for the last couple  of years and so I sent the x-rays around to my partners to ask who would fuse the subtalar joint  and who would take it down because my patient wants the takedown on the ankle fusion and I  struggle with this decision we published on the difficulty of getting a subtalar fusion after a solid ankle fusion and as we know a normal subtalar fusion without any other inciting  events is about a 95 fusion rate but if you have an ankle fusion above it then that goes down to  about 70 so it's not a slam dunk as you indicated taking down a solid fusion in a good position  frequently doesn't yield a lot of increased motion I was surprised by that last paper because  my experience has been in the ones that have non-union you get pretty good motion like you  showed in the ones that have been solid like this for 15 or 20 years you don't get so much motion  so this particular case I would probably and you said this lady was in her 50s  now she's 51 yeah but before you give me your final answer I'm gonna I'm gonna increase the  complexity maybe Dr. DiIorio said he doesn't need long limb films but I sure do so so here's her long limb film now does that change what you would think about for this patient  it certainly does because she's got miserable malalignment the entire length of her extremity  and I can't believe that she doesn't have a painful knee as the way that situation is occurring right  there and with the non-union of the fibula and the deformity below her hip knee ankle axis probably  if you drew a straight line down there may not be off too much but her knee certainly oh yeah  there you got the line right there so she's not terrible but the knee is pretty terrible  so the real question is are you gonna force her to get her knee done before you do anything to  her ankle yeah so I was hoping her knee was hurting but she really swore to me that she didn't have knee pain so that was unfortunate for me fortunate for her so I sent her one of  my colleagues and and and he worked on the tibia to get the tibia straight you can see here  that she had a tibial osteotomy and she's not perfect but she's better and then underneath that  I attempted to do what we said that we probably shouldn't do but I did do an ankle arthrodesis  takedown and I used a stem implant and I found that when these are long-standing uh ankle arthrodesis the the bone changes the the cortex hypertrophies and the center of the bone  really is almost gone and so you have a shell of bone but the inside there's not much there  and the other thing is as we talked about high incidence of complications particularly malleolar fracture and even though you check multiple times your malleoli end up much thinner  than you had planned so you here you see a plate protecting that medial malleolus and here is the  post-op and remarkably this ankle has stayed in there for about six years now almost seven years  I believe and she's doing pretty well but when you look at her motion exactly like you said  she doesn't get very much motion I would argue a lot of this is coming from the subtalar joint  and the talonovicular joint and calcineal cuboid joints it's not really coming from the ankle  but certainly this is more motion than she would have had had I put in a TTC nail and fuse the subtalar joint so one of my take-homes one more question real quickly I know we've  finished up this session but one question she came in with subtalar joint pain you said and so you  did an ankle replacement how does how does what's your pain level now does she have subtalar joint  pain or did you should you have done some subtalar joint or was it okay not to do anything  well she hasn't had a subtalar arthrodesis and she is happy now is she as happy as a primary ankle  absolutely not and she still has discomfort she still has some pain she still has some stiffness  but she is in some ways good enough that she hasn't come back for any additional procedures and hasn't had any additional fusion so the question is how do you you know judge success  in a case like this if you say success is to avoid additional arthrodesis and maintain some motion  it's successful but to say that this patient is pain-free is really not true but she's you know  glad she did it but it's a lot of surgery one thing that I would bring up I mean these are beautiful examples but in the one that has a solid fusion that's a classic case for PSI  it's very very difficult to intraoperatively cut out to know exactly where the joint line is but if you pre-operatively plant it and have a template that lays on there perfectly  then you can put up your protective medial and lateral screws you can go ahead and make your  cuts and you'll have the joint line exactly where it needs to be so if you're thinking about taking  down a solid one I would advise you to think about using a patient-specific CT guidance  well may just be a great transition to Carl coming in is it all right Constantine if we  move on to Carl's lecture absolutely let me make sure have I stopped sharing are you guys good  yeah perfect yeah I see that okay yep there we go perfect these are my disclosures I think my biggest disclosure is I'm the youngest  speaker on this panel talking about one of the harder subsets of patients to take care of but  while I've been humbled in 10 years I've also grown up quite a bit in 10 years so  obviously the the rate of primary ankle replacement is exponential and thus follows revision although  not quite at that ratio I think the key to revisions is getting better at primary to lower that percentage but this will be my get on a podium for a second here you know I think  it's important with these revision cases to be responsible and realistic for the patient be  their advocate not their hero be their doctor do the right things rule out infection get the old  records get the pre-op x-rays get as many x-rays as you can but then also you know do the usual  things you would with a primary plan look at your soft tissues length alignment and the  plan look at your soft tissues length alignment stability full length views the goal is to try  to maintain ankle range of motion single stage if you can in stage if you need there's no shame in  that maintain reinforce the bone stock whether that's your malili or getting a hindfoot fusion  to support implants below is important there's some other techniques which I'll highlight in a case  and you want to get comfortable using a revision or other several revision systems and augments to  maintain your joint line and use your resources you know we we use indications conference but also  our plastic surgeons our vascular folks are very important in these patients when you haven't done  all their surgeries their soft tissues are bad and their pulses may be questionable and I use TTC  as a last resort. Dr. Levin taught me a lot about orthoplastic approach but I think the same holds  you know don't skip ladders and don't step steps in the reconstructive ladder and the same holds  with revisions don't don't do procedures that don't have exit points for patients or at least  where the exit point is less desirable try to do something responsible for the patient that leaves  them options if it's not work out and I think the most important thing is don't forget about patient  expectations more than two-thirds of patients have higher expectations than their surgeons  this is from Constantine's group I think that's a great study so this is a 70 year old healthy lady  came from northern California I think she thought her last my last name was Dr. Easley but it was  actually Schweitzer in any event she had a closed triangular ankle fracture in the 80s that healed  and she did well for a long time she developed post-traumatic ankle arthritis a decade later  and underwent a star or mobile bearing ankle replacement no history of infection there issues  with wounds she had increasing pain in 2018 and a salvage of this construct was attempted with a  subpillar fusion that ultimately failed due to probably survival of the tailor bone and avascular changes she was told it really wasn't revised and offered a TTC fusion  she really enjoyed her ankle for a long time and wanted some hope that could motion could be maintained all of her workup was negative for infection  she has an abundance of osteolysis and you know blooming cysts around the medial side on the  distal tibia and underlying the tailor component as well prior hardware primarily at the subpillar  joint from the attempted fusion so you know why did this patient fail you know I think the problems  that she is experiencing and she wants her motion she's experienced avascular changes to her talus  maybe that was an insult from the subsequent subtalar fusion she's had subsidence she has an abundance of cysts and poor bone stock with osteolysis she has alignment issues her foot  is pronated her ankles and valgus and these were kind of the options that really that we talked  about you know ultimately she decided at this point she was willing to undergo a staged Heinfeld  fusion explant with eventual conversion to a revision system and we'll kind of go through  how that might work so in general preserving bone stock not trying to burn bridges for the patient  leave them with the joints that they have but don't bother them revise the ones that you need to and don't skip steps on the reconstructive ladder you know don't always try to avoid  drinking the poison right away so this is stage one of her procedure we explained everything I still took deep cultures I did kind of a modified revision triple orthodesis to try to  get as much bone stock around where her tailor component will be we bone grafted as many cysts  as we could added some protective screws on the medial side and I basically assembled a cement spacer there to hold her in a corrected position and maintain her joint space and  ligament attacks tips I've learned here and of course I've been humbled not all pieces go this  go this way but smaller screws they're smaller diameter is important they're going to come out  I tend to leave them a little proud because they're coming out in a few months and then  really build the basement for what will be a revision system this is a CT scan I'll get usually  around two and a half to three months post-op at this point she's doing a little bit of weight  bearing on this to try to maintain some bone health she's healing it incorporating it and  has some improved bone stock to work with and of course the medial malleolus screw I'm trying to  put it up the medial side so that we don't have to worry about it at her subsequent procedure because ultimately I'm planning for an intramedullary based system here  so stage two which is about three months after her stage first stage surgery removing some of  the prior hardware we have her ankle aligned neutrally we're doing revision cuts in a frame  at this point the spacer is in and we're going to do a flat cut really across the dorsal navicular  to try to get as much flat bone to put a prosthesis ultimately I had to build the joint down with a revision system that has tibial augments to restore the joint line and I did  attempt bone grafting of this contained tailor defect but I really had trouble spanning it even  with a revision talus that bridged more and so I had to kind of come up with this technique which  ultimately I would give credit to Dr. Haddad for showing this and I thought this was really  probably the best option at this point to give her a tailor component stability so essentially  pouring a thing of cement in there and then you know having screws or essentially rebar to support  that or to strengthen that region and that seemed to work for her ultimately she's about two and a  half years post-op obviously there's a lot of story to be told but this is just one approach  for how you can perhaps do a lot with a little and salt really kind of went through the checklist  and tried to address all the issues and I think that's important to just make a list of the  problems you're trying to solve and try to find a reasonable and responsible way to try to address it  of course sometimes the tibial component is fine it's well fixed it's well aligned you don't have  to deal with it and you can either do a single stage or a staged approach to revise the tailor  component and get more bone stock by doing a sub-tailor arthrodesis below so in summary I  have a checklist I go through all the important things the biology the structure the alignment the  function the patient factors do all the homework rule out infection other pathology do the legwork  get the old x-rays and notes and just ultimately be realistic and responsible for the patient make  them understand that this you know is obviously a limb salvage attempt here and we're trying to  move them forward in a way that will give them options if this were to not work and really try  to favor using the patient's bone stock over custom implants although I would argue at times this Sam will probably show that's probably critical and important in terms of surgical  the standard principles apply you have to really get comfortable with an uncomfortable amount of  bone and for those cases I probably lean on staging it but maybe that's me just earlier on in my career minimize bone loss when you're explaining it that's important but oftentimes  these metal components are released build a foundation like we showed underneath in the  hind foot solve all the problems on your checklist and become fairly comfortable with revision systems but ultimately primary systems as well I would argue is more important  so we can limit this percentage in the future  thanks extraordinary carl great work I didn't mention that it was a transition do you ever use PSI for revision surgery?  Well, I use a lot in school disclosure for primaries.  I find that oftentimes the landmarks are less reliable and some of the situations are less predictable in the OR. I haven't done a whole lot of PSI with revisions.  I tend to use more intramedullary total ankle,  which could be done with PSI, but I really feel in that situation, the frame is my friend.  Right, Jim, what do you think? You got some words of wisdom on revision, total ankle replacement. You've certainly done your fair share of those.  Yeah, I think Carl did an excellent job here and I think it looks very, very good. I didn't talk to Hadad about the use of cement  and it's interesting because I know he talks about that now, but he told me that whenever he used cement, it looked good for three to five years and then ultimately it failed.  So you may be saved here by the fact that you have such a good contact of the tailor component with the anterior talus, where there's still decent blood supply.  So that may save you and it may be an indication where all you have to use is a little cement filler. But when I was doing total hips,  I made it a big point to always be putting in bone, always be putting in bone, filling all the defects with bone, because I thought, you know,  maybe I'm the one that's gonna have to come back and redo this. And if that's the case, then I wanna have more bone there. So this is, I think, a novel technique now.  It may not last into the long future, but on the other hand, if you had to revise it, you could simply go in there and take out the tailor component and this time bone graft it  and try to get that stable there. So cement will loosen in almost all cases, which is why we don't use the cement for total ankles. But your planning, your revision,  your protection of the malleolus there, they're all perfect. So hard to beat success.  Quite extraordinary. Great, great work.  Tell you what, given that we have 20 minutes left, why don't we move on to get Sam to tell us a little bit about the, what Carl mentioned, but the 3D printing options,  things we can do when it really doesn't seem that revision isn't even possible. Sam?  All right, thanks everyone. So yeah, I'll talk about 3D printing and my experience and maybe some words of caution as well.  So here are my disclosures related to this topic. I do have stock options and I saw them for 3D printing companies. But I think the biggest question is when and why  to use 3D printing. And in my hands, it's really the majority of cases are those on the left here. And that's when there's too big of a bone defect,  whether it be in the tibia, tails, or navicular, to support a current implants. And that's whether we're talking about a primary, a need for a primary total ankle.  Or  but there seem to be  a number of times where I'm trying to replace an ankle  for the, me and my, amongst my colleagues here have designed some custom total ankles to meet the needs of the patient's anatomy.  And so those are the two biggest indicates for use for.  3D printing. And certainly on the left here, the bone defects are the majority. If we look at this case, seven years out from a total ankle and it had been doing great.  He was actually lost to follow. Let me stop you for just a second. We're getting you, but we're missing just a little bit. Occasionally you phase out.  Do you think if you turned your camera off, do you think we could just hear with your voice, do you think that'd be a better signal possibly?  Let me try that. Can you guys hear me now? Yeah, I think it may be a little better. Okay, so 74 year old male, seven years out from an ankle, total ankle,  really has been doing well with activities,  no pain, except for achilles.  And he came in to see me and his radiographs and maybe the tail dome may be collapsing a little bit, but there's some lucency underneath the talus.  And so here you can see on CT scan  that shows a large cyst underneath the tailor component. And I thought about trying Carl's technique where I could maybe do a subtailor fusion,  but I felt when the cyst extends this low, trying to get a good fusion mass would not be ideal for this patient. And basically he did not want to go to a fusion.  So we decided to print a 3D talus.  His tibial component was stable. And 3D talus with mapping the star poly here and doing well several years out. And so I think this is kind of the common reason  why we use 3D printing, but it can get much worse. So this is a 67 year old female who's already on her third ankle placement.  You can see this in multiple directions.  This is already a custom inlay.  And there's no bone stuff.  And she also decided to get her old implant out, had to make a cortical window, used an intramedullary implant to bypass that bad distal bone.  The proximal fixation, implanting the real implant.  Yeah, we're losing you a little bit again. Is there anything we could do to strengthen the signal just a little bit more?  Mark, sometimes if he uses the phone rather than the computer, it'll work.  Sam, can you hear us? How about now? Can you guys hear me now? Yeah, I can hear you well right now. Let's see if we can keep it going.  All right, so here she is one year out and you can see she has great motion and she's very pleased with her results. But I have to use a word of caution  that this 3D printing is great and it can solve a lot of these techniques. You have to be able to handle any complications that should arise.  And one of those could be soft tissue stability. And here's another case where a failing total ankle with not great soft tissue.  I would never do a revision replacement in this case. And we used 3D printing to do a solid fusion here.  Here's five-year follow-up. So in summary, just to speed things along, I'm cautiously optimistic about this technology. You have to understand it.  You have to be able to handle complications. And we all need to do as a...  We need to really put some restraint on these.  I just wanted to show this last example  when you don't have a lot of bone stock. This was a metastatic renal cell carcinoma, still tibia and total ankle replacement. So thank you.  Yeah, that's great. We missed just a little bit of it, but luckily your picture is worth a thousand words. It's extraordinary work.  Cesar, you have some experience with weight-bearing CT  and planning complex cases. Have you had some experience with custom implants in total ankle replacement?  Yeah, I think I'm just starting. I mean, Sam is so advanced on these that he 3D printed a robot to give his lecture. So it was actually not there.  That's why it sounded like metallic.  So Sam, I mean, there's so much excitement with...  I think the most common thing for people that are not as advanced on indications like you guys are doing with distal tibias and fibulas and naviculars and all this good stuff.  But total talus, I think, is where people are getting more excited. And I feel that sometimes the excitement is too much of an excitement, where people are just like low threshold,  saying, oh, this talus is gone. Let's get it out and put a total talus there. So I know it's a tough question to answer, but I mean, can you kind of frame, try to frame?  Let's just, in a picture, let's say of a bone loss in the talus, like you show what case there, or a vascular necrosis. When do you go more towards, Carl,  how do you decide if you go more towards preserving bone and trying all the other options before going into a 3D printed total talus?  And when do you say, now this, in my experience, the total talus is gonna be the best bet here? Because it's, I'm afraid that we might be going without having enough data  and without having adequate training sometimes to just say, let's pop off this talus and put a new one there. So if you could talk a little bit about that.  I know it's a hard, difficult answer because it's different cases, but. Yeah, we could probably give a whole lecture, but yeah, I think I've, I certainly was  doing a lot of the total tali and I've kind of reigned in my indications and try to use the patient's own bone when I can at this point.  I think we're gonna start to see more and more failures of the totalus and therefore I've been very, very more conservative about doing a total talus, but there are indications  where the talus is just not good enough. And while Carl's technique is very good, there are times it's just not gonna work if the entire talus is involved.  And I think in those cases, we don't have many other options if you wanna maintain motion. And so when there's really widespread talus involvement,  that's when I'm doing the total talus or variant of it. Can you explain when you say we'll see some total tali fail, what do you mean by that?  Do you mean that there's adjacent joint arthritis that develops around it or that the total talus itself just doesn't function?  Yeah, the talus itself is not gonna fail. It's, I'm starting to see adjacent joint arthritis. I'm actually happier to see a patient  that needs a total talus, but also has ankle arthritis so I can do an ankle replacement as well because I'm starting to see the ankle in a non-replaced total talus,  the ankle cartilage wear out and I'm starting to see subtalar pain. And so I'm almost happier if there's already adjacent arthritis, joint disease that I can build into,  that I can treat during the total talus operation. And you showed some extraordinary cases.  You can tell me about total talus plus total ankle,  which my understanding is called a tater. So you can put that good Southern tater in there. But then if you also have subtalar joint arthritis or talar navicular arthritis,  can you actually get the calcaneus and for that matter, the navicular to fuse, to actually get bone on growth or in growth into a total talus?  Well, that's the hope. I have some patients where, and it's very hard to see on a CT scan what's actually happening inside, what's growing into the total talus,  but I have some patients with a subtalar fusion that are pain-free. I just saw a lady in the office today that has the tater with the subtalar fusion  and she can do 12 hour nursing shifts without any pain, but she also volunteers at a dog rescue. And as soon as she gets on some uneven surface, she's starting to have pain.  And a spec CT shows that it lights up all along that subtalar interface. And so I have, she's probably not fused at all there. And so that's something I have to deal with.  Do I pop out this implant, put a new one in? Do I just try to graft that area? And so these are, again, these are all, it's uncharted territory, things we really don't know.  We don't have a good treatment algorithms on how to deal with these potential complications. And that's why I think we need to exercise some caution with them.  Yeah, and I definitely want to hear again from Cesar. There's one question that's come in, what the million dollar question, no pun intended,  but how do you get insurance to pay for 3D printing?  I don't know. So I will say that the interesting thing, and I don't want to put an institution, like pit it against others, but when I've gone back  and every time I publish on 3D printing, the reviewers always want to know what was the cost to the patient of these implants. And I've gone through every one of them  and none of my patients have actually gotten a bill for the cost of the implant.  And so it is hard to do at certain institutions. Fortunately at ours, we've been pretty lucky about being able to get these through our institution.  Yeah, Cesar, if you have, you're doing the comments here, maybe we can finish that up in a couple of minutes and then we have a couple of other questions  from our participants that I want to make sure we get to as well.  Well, the other question I had for Sam, it's also very tough to answer because it's very broad, but I mean, you have been pushing the limits with this 3D printing.  What do you think is the limit, like in terms of limb salvage besides infection, right?  So we're not talking about, but bone loss and the need for bone marrow integration and different bones, how, because of your experience, how have you been framing that in your mind  and say, maybe I'm going too much here? What would be too much for you?  Yeah, that is a tough question. I mean, you know, I've done some pretty tall cages for distal tibial bone loss and there's no way in a body to incorporate or bone to go through.  And it's going to fail. I haven't seen an implant actually fail yet, but it's coming, it's coming. And then, you know, the future of the problem is  that I'm putting these big chunks of metal in people and they can get infected. I know you didn't want to necessarily go that route, but I have a couple that have gotten infected  and then I have to pull the implant out.  And is it a BKA or patients don't want to go  that retrofusion. And so there's, there are a lot of potential problems with these implants. If you'll be bonding, we'll print bone in the lab, but we're nowhere near that.  Yeah, we're losing a little bit again. Let's see if we can ask a couple, I got one more 3D printed question. So Sam, I'll direct that at you.  And then we have two other questions are more general. When you use a 3D printed cage, what type of bone graft do you use to put within the cage?  That's a great question. There's no data to support either the use of bone graft or then going to which kind of graft.  If it's fusion procedure and I'm taking the fibula, morselize the fibula, put that in there. There is some animal data that shows that BMP  does help incorporate bone into these cages. So I'll usually use some BMP around it, but otherwise even I'll go as little as nothing or putting some DBM inside the cage.  Great.  Constantine, you had mentioned this earlier, but in valgus cases, how do you know if the deltoid is competent preoperatively or incompetent preoperatively? Is there any way,  is there some type of stress exam you can do or use fluoro or ultrasound, but how can you preoperatively determine if the deltoid ligament is competent or incompetent?  If the, typically if the medial border of the talus  is lower than the anterior colliculus of the medial malleolus, then you're in a little bit of trouble. So the two warning signs for me are lack of erosion  of the lateral tibial plafond where the talus is pivoting on the tibia. And then if the medial shoulder of the talus  is below the anterior colliculus of the medial malleolus, those two things make me think that I'm gonna have a lot of trouble with the deltoid during surgery.  If there's lateral plafond erosion  or if the talus hasn't quite cleared the medial malleolus, then typically you can, you'll be okay. But that's not within the evidence that I know of that I don't, you know.  That's level five, it's level five evidence. That's pretty good. That's level six evidence, that is not level five. Jim Nunley, you taught me how to do,  how to identify deltoid insufficiency in athletes. So I do an anterior drawer test, but with external rotation. Does that work in arthritic patients too?  Unfortunately, I don't believe it does. I think there's too much global laxity to be able to make that a reliable test. Yes, I think what Constantine said,  but I think that true deltoid insufficiency in ankle arthritis is a very rare phenomenon, not a common.  Got it, all right. We have time for one more question. So there was one about, and this is open to anybody. How do you deal with posterior bony hypertrophy  in total ankle replacement? So you've done your total ankle, and I think Jim Nunley and Jim Deory, you published a paper where it's over 90% of patients  that have had a total ankle will get hypertrophy or hydrotrophic ossification posteriorly. One, is that a problem? And two, if you see it, what do you do about it?  Well, it's not normally a problem, but I think one of the things is to make sure that your tibial component,  if anything, projects slightly posterior to the tibia. If you leave even a millimeter of the tibial raw bone posterior to the prosthesis, then you're going to get a sheet of bone  that'll eventually form. Most of the time, while it impedes motion, it's asymptomatic. But I have gone into patients on revision cases and made through a posterior medial incision,  taken out that bone specifically. And that made a difference? Yeah, it makes a difference in terms of getting more motion. Of course, it may come back, but it can be done.  Sam Adams, to Jim DiIorio's point of getting full posterior coverage, do you think there's a place, or to anybody, and Jim Nunley, you mentioned patient-specific instrumentation.  Is there a place for patient-specific implants that would get full coverage every time?  I think there's definitely room for that, and it'd probably be the way of the future.  But right now, it'd probably be cost-prohibitive.  Got it. So on that note,  I think we've come to the end of our session. So I think we've answered all the questions, had quite a few attendees on, and I'm excited. Thank you, all of you, for taking the time,  particularly East Coasters here. We're past a lot of people's bedtime, but I think it was really fantastic. It's recorded, so it can be watched any time in the future.  And I'm going to turn it back over to Lucas,  our host from the AOFES, but we're all honored to be included in this webinar. Thank you very much.  All right, thank you, Dr. Easley. I just want to remind all the attendees once again to complete the evaluation CME claim form  following this webinar, and otherwise, have a good night. Thank you, everybody. Good, thanks. Good job. Thank you. Bye.

Video Summary

In the video, the panel of experts discusses managing complex ankle arthritis and deformity with total ankle anthroplasty. They explore various approaches, including the anterior and lateral approaches, and provide case examples to illustrate their decision-making process. The importance of correcting deformities and aligning the ankle properly is emphasized, with techniques such as ligament releases and osteotomies discussed. The role of weight-bearing CT imaging in pre-operative planning and post-operative assessment is also highlighted. The speakers acknowledge the challenges associated with ankle deformities and emphasize the need for individualized treatment planning and intraoperative decision-making. They also discuss the use of 3D printing in total ankle replacements, particularly in cases with bone loss or large defects, and caution about understanding the technology and potential complications. The topic of insurance coverage for 3D printing is briefly touched upon. The panelists share their experiences with revision surgeries and the use of custom implants in complex cases. Overall, the video provides valuable insights into the management of complex ankle arthritis and deformity with total ankle anthroplasty, showcasing the expertise and opinions of the panel of experts.

Asset Subtitle

Moderators: Mark E. Easley, MD
Faculty: Samuel B. Adams, MD; James A. Nunley, MD; James K. DeOrio, MD; Karl M. Schweitzer, MD; Cesar de Cesar Netto, MD, PhD; Constantine Demetracopoulos, MD

Complex ankle arthritis is a challenging problem to treat with total ankle replacement (TAR). In this webinar, expert faculty will discuss current evidence and options for managing these cases with TAR as well as algorithms for correcting deformities associated with ankle arthritis.

At the conclusion of this webinar, you will be able to:

Identify complex ankle deformities associated with ankle arthritis
Understand available treatment options for managing complex ankle arthritis with total ankle replacement
Identify treatment algorithms for correction of complex deformities associated with ankle arthritis in conjunction with total ankle replacement
Understand current evidence in managing complex ankle arthritis and reported outcomes of such pathology

Keywords

complex ankle arthritis

total ankle anthroplasty

anterior approach

lateral approach

deformity correction

ankle alignment

ligament releases

osteotomies

weight-bearing CT imaging

pre-operative planning

post-operative assessment

3D printing in total ankle replacements