Good evening. On behalf of AOFAS, I want to welcome you to the 11th webinar of the 2021 Foot and Ankle Focus Series. Tonight's program, Total Ankle Arthroplasty, will be moderated by Dr. Tim Daniels. Joining Dr. Daniels are Drs. Michael Bragui, Mark Easley, Beate Hennerman, and Murray Penner. You could find their full biographies and disclosures in the program document posted in the chat box and the PRC. The 2021 webinars are provided free to AOFAS members and orthopedic residence fellows with funding from the Orthopedic Foot and Ankle Foundation, supported by grants from Arthrex, Inc. and Stryker. 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. Registered physician attendees may earn 1.5 hours of AMA PRA Category 1 CME credit by completing an evaluation in CME claim form at the end of the webinar. You will be able to 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 Physician's Resource Center at www.aofas.org slash PRC in approximately one week. We encourage you to ask questions during the presentations. To send your question to the faculty, please click the Q&A tab on your navigation column. I will now turn the program over to Dr. Daniels to begin. Thank you. Thank you, Jennifer. We have an exciting program tonight where every one of these topics literally could be a 60-90 minute webinar on its own. We're all giving our talks either from our offices or homes, so we like to think of this as a fireside type of chat. I've tried to pick as interesting topics as we can surrounding total ankle replacements, and I'd like to start the evening off with Murray Penner, who's going to talk to us about total ankle replacement over fusion. Are we at the tipping point? Murray, the floor is yours. Great. Thank you, Tim. Thank you so much for the invitation to be a part of this webinar. I think this is a great panel and a great bunch of topics. I'm just going to share my screen here now and get this underway. Here we are. This is a little bit of a different topic to maybe start off with, but I think we're going to get into some of the real meat of the matter with the subsequent talks. This is really more of an introductory and a conceptual talk, but hopefully you'll find it a little bit illuminating and maybe a bit thought-provoking. These are my disclosures. I'll start with a bit of just a thought experiment for you. This is a patient that you'd like to see in your office on any given day, a 44-year-old healthy mechanic with ankle arthritis that looks like this. The question I'd ask you to ask yourself is what would you preferentially recommend to a patient like this at 44? Would you be recommending ankle replacement or would you be recommending fusion? I just want you to ponder that for a moment. If you're one of those fusers out there, what would it take to convince you to recommend an ankle replacement instead? What is it that would tip you over in your thinking? Well, that's what this presentation is really about. The tipping point concept, this is a concept that really gained popularity with the book that Malcolm Gladwell put out in 2000 and in itself became a metaphor for its own subject matter. You can see that in academic abstracts and titles, the term tipping point went through its own tipping point at around 2000, just after the book came out, really illustrating in real terms exactly what it meant to write about. What is a tipping point? Well, Wikipedia describes as a point in time when a group rapidly and dramatically changes its behavior by widely adopting a previously rare practice. You can kind of see where this is going. What does this look like? Well, at least for some of you in the audience, you'll recognize this. This is Napster. This is really what started online music and streaming and downloading of digital music. It went from a nothing to 15 million users in less than a year's time. That went through a real tipping point. What's this all about? Well, some of you might recognize this device. It's a fax machine. It's one of the very first ones. You have to think to yourself, the first person who ever bought a fax machine must have been a bit crazy. Over time, fax machines took over and they became ubiquitous in the mid-'80s. The question is, what led to that? We see that when the price threshold was hit, then all of a sudden usage just took off. The real question is, what are these factors? Is it just price or are there other factors that drive these new technologies through the tipping point and onto greater success and adoption? This concept is very relevant, I think, in anchor replacement today. When we're talking about innovations and new technologies, and to a certain degree, anchor replacement may or may not seem like a new technology to some of us in the audience anymore, but if we think of it as an innovation, how does that move along this kind of a curve? Where is the tipping point on a curve like this? Well, Malcolm Gladwell describes this tipping point as occurring as the usage and uptake becomes exponential. Jeffrey Moore has written a lot about this. His book called Crossing the Chasm is actually a Bible, if you will, on this topic. He describes this gap between the early adopters and then when exponential growth takes off and describes that as being the chasm. That's this area here. We can see this kind of effect of crossing chasm when you look at VHS and Betamax technologies. Some of you might not even remember what those are, but in the late 70s, this was definitely a technology war between two different videotape technologies. Around 79, 80, all of a sudden, VHS clearly won the war, so to speak, and Betamax and Blu drifted off. The question is, why would that be? The Betamax people clearly couldn't cross the chasm the way that VHS could. There's lots of reasons potentially for that, but self-evidently, if you fail to cross it, it's going to be catastrophic for your outcome. What is this thing called the chasm that we're talking about here? Well, it's that divide between the early market and then the mainstream market. It itself is divided into four distinct parts. There's the part, and this is going to sound familiar fairly soon, I think, for the ankle replacement topic. That first stage is really complacency and marginalization. People thinking about it go, it's not a big deal. As it gains a little bit more popularity, it becomes ridiculed and made fun of, but that eventually leads to real criticism as people realize this isn't going away. Ultimately, that real criticism can then become acceptance and a recognition that this is, in fact, legitimate. Is there a parallel here with ankle replacement option? Well, I personally think so, and we'll have more on that in a minute. How is it that you go about crossing this chasm then? How do you move from these early adopters to this more significant majority? There's something called Maloney's 16% rule in marketing. When you're in that first phase of early adoption, before you get to the chasm, the marketing and the novelty or the uptake of this new technology is really based on its own scarcity. The early adopters like things to be rare and scarce, and that's, in fact, its own appeal to drive uptake. Once you get past that 16%, you reach the chasm, you have to get across that in order to get the early majority and then ultimately a larger majority to adopt. What does it take to do that? It takes social proof. What exactly are we talking about here? I'll try to explain that through a great example of a tipping point in total knee replacement. There's a little bit of a history repeating sense here when we talk about knee replacement and ankle replacement. The current state of ankle replacement is really analogous to the state of knee replacement, perhaps two or three decades ago. It's worthwhile understanding the role that revision knee replacement played in this. When we look at the data on knee replacement going back to the late 1990s, we can see a really rapid and steady rate of growth. This is in US data of knee replacement numbers per year. What you also notice is a really large increase in the percentage of knee replacements being done in young people in late grade. When you see this depicted another way, again, it's this group of young people, 45 to 64, that saw this exponential explosive growth through that time period. This is a bit more concentrated data over a longer time frame out of the Mayo Clinic showing this really rapid growth that occurred around the year 2000. It wasn't just in the US. When you look at UK joint registry data, we see that very same explosive growth in total knee replacement numbers occurring starting around 2000. Again, more notably, looking at the UK data, it's not just the total number, but it's the percentage in these young people that we see as the main driver of this explosion. What can we conclude from all of this? Well, around the year 2000, the rate of knee replacement, as we just saw, skyrocketed. The rate among younger patients, 45 to 64, even more so, they were the real drivers of this. Why was this? Well, the reason was social proof that knee replacement crossed the chasm at that point. In the 1990s, knee replacement was already popular, but for a large percentage of people who needed it, these young patients with knee arthritis, it wasn't really being used by the majority of surgeons. It was only being used in young patients by a few early adopters who were often ridiculed and criticized. During my residency, I saw that very distinctly, but by 2000, social proof was on the way. What do I mean by that? Well, by 2000, the literature started showing good results for revision total knee replacement. Meta-analyses showed re-revision rates that were acceptable. Lots of articles, lots of presentations were concluding that revision knee replacement was now finally an effective procedure for failed total knees. What was it that improved these outcomes that made it become acceptable? Obviously, there's an accumulative worldwide experience of knee replacement over many years, but more specifically, it was a development of these modular dedicated revision systems that increased capability, they became easier to use, and more specifically, they were able to produce reliable outcomes, giving surgeons a lot more confidence. It was the advent of these dedicated modular revision implants that made the outcomes of revision knee replacement more reliable. That gave surgeons the confidence then to broaden their indications for primary knee replacement to include previously excluded groups of patients, primarily these younger patients. These were the ones who really stood to benefit from the increased quality of life offered by knee replacement. That then drove knee replacement through that tipping point. Long explanation, but how does this then apply to ankle replacement? Well, to know this, we need to know where we are with ankle replacement in its current adoption cycle. Let's look at the usage around the world. In the US, it's actually very hard to get good data. This isn't US data, this is California data. It's the state that we can have the easiest time collecting sort of through publicly available data. We see quite a dramatic increase in the rate of ankle replacement since 2005, around 900%, in fact. We don't see that notice quite so significantly elsewhere, although in the last five years in the National Joint Registry of the UK, we see a dramatic increase as well, about 78%, nowhere near 900%. In Australia, we see a very similar trend through their joint registry as well. When we look at that UK Total Ankle Registry data a little more closely, we see that in 2017, there were 135 surgeons performing ankle replacements, which worked out to about a mean of 5.4 per surgeon, but a median of only three per surgeon. When you look at it, those who did more than 10 total ankles, it was only 17% of surgeons. That number should sound familiar because it's very much like that Maloney's 16% rule. These were the real early adopters and the innovators. That's kind of where ankle replacement really was in 2017 in the UK. Overall usage of ankle replacement in the US is definitely increasing and seemingly fairly rapidly, but outside the US, data suggests the rate of increase is a bit slower, but still increasing. This UK data does suggest that ankle replacement is still a technology primarily being used by early adopters, but it's at that point now. In short, ankle replacement seems to kind of be stuck right at the chasm as we're talking about at that 16% rule. What's it going to take to change this? What's it going to take to change from this to this? That's the question. How does ankle replacement go across the chasm and reach this tipping point to become sort of the primary option? As stated by Chris Maloney in his Maloney 16% rule, we need to generate social proof. What is this social proof? In my mind, it's really a demonstration of four key attributes for ankle replacement. We need to be able to show that ankle replacement results are truly and honestly better than fusion, that durability is reasonable, it's revisable and fixable when it fails, and that it is achieving widespread use. Are we there now? I think we're actually very, very close to that tipping point. Why would I say this? I think that ankle replacement has really crossed most of the way across this chasm that we're speaking of. It's gone from being marginalized and ridiculed. It's been now subject to some very real and legitimate criticism, but now it's moving to a point where it has gained broader acceptance in the foot and ankle community. I think, again, the four keys to proving this sort of socially, these are emerging now. I think we are seeing that results are actually better than fusion. We are seeing durability, revisability, and widespread use. I'll get into each of those here. How can I say that? Well, I do think that we are now seeing that results from a patient perspective truly are better than fusion. We now know from this COFAS paper presented at IFAS with the Takakura Award quite some time ago now, that total ankle replacement better meets patient expectations than fusion does. We also know from a number of gait studies, this being a particularly good one, that gait after ankle replacement more closely resembles a normal gait than it does after ankle fusion. We also know, we're just gonna jump back a little bit here. We also know that in complex ankles, the COFAS type threes and fours, we've seen that the outcomes reported by patients are better for ankle replacement than for fusion. And now also in the less complex ankles, we've also published in that through the COFAS group that results in ankle replacement are also better from a patient-reported outcome perspective than for ankle fusion. So in summary, I think results really are truly starting to show that ankle replacement does indeed, or can indeed provide better outcomes than ankle fusion in most situations now. Also durability. Well, I think durability is now reaching that of total knee replacement. We see typical total knee revision rates as published very recently here, relatively recently here, running between six and 12% over the first five and 10 years. When we look at older revision rates for total ankle, it's much worse than this, as you see here. But when we look at newer data, we see numbers that are now much closer to what we've seen in the knee replacement realm at the corresponding timeframes. And even in the latest studies, even in this early kind of data, we're seeing numbers that really resemble similar early experience numbers for knee replacement with 1% revision rates admitted at a very early timeframe, but still at a good, sort of in a large group of cases. And then at that midterm, we're seeing numbers again that are very analogous to that five-year data for knee replacement. We also know now that revision is viable and unfortunately, though, published modern revision outcome data is still lacking, and that's probably the linchpin that we need, but it's undoubtedly coming soon. We now have modern implants, techniques, and instruments that are available to address most of the tar failure modes that are out there and can do that successfully. We now can take a problem, so we can take a problem like this with significant subsidence, large degree of bone loss, and sort of poor bone quality, and still manage to convert that into a very well-functioning ankle replacement by restoring bone with bone graft techniques. We can span across large bony defects. We can fill large bone defects, and we can still do all of that while maintaining appropriate biomechanics. So our capability now compared to 20 years ago is dramatically different. And lastly, this expanding use concept of social proof. Is ankle replacement gaining widespread use? Well, I would say that if you look at that UK data, there are now 140 surgeons out of 400 members of their foot and ankle society that are now actively using ankle replacements. So I'd say that's a yes. The results do suggest that, or the national joint registry results suggest that results are satisfactory even when ankle replacement is in wide use, not just when it's in the hands of a few select experts. There's no real similar numbers in the US, but the steadily increasing number of ankle replacements received per year does suggest that reasonably widespread use is now beginning to occur. And so those four factors that I think really do demonstrate that we're getting there. So I do think that toe length replacement using the terminology that we've been talking about currently is still stuck in the chasm, but I do think that social proof, the social proof that is needed to escape this and to get to the tipping point is now readily emerging. I do think we are seeing that ankle replacement can produce results that are better than fusion. We are seeing good durability in these newer designs, and we are seeing that there is revival, that revisibility is out there and use is increasing. And so based on that, I do think that ankle replacement finally now it is reaching that tipping point. Thanks. Thank you, Murray. That was excellent. It reminds me of Truman who said, the only new things in the world is the history. We don't know that review of total knees. You know, this is where I'm feeling a little bit long in the nineties. I still remember that. I still remember when hip replacements were relatively new intervention and now they're the standard of care. Absolutely. Beat, we'll have you up next. So Beat is gonna talk to us about total ankle replacement in the valgus arthritic ankle. Floor is yours, Beat. Thank you. So having me in this exciting webinar, Tim, I will talk now about total ankle replacement in the valgus arthritic ankle. I think that's still a relevant problem. You see here my disclosures. The problems in the valgus ankles are, we have a asymmetric joint load, as you can see here. And don't forget, we have a force vector of triceps surae that acts eccentric and acts as a pronator of the hand foot. So these two elements are very important. As a summary of problems in the valgus ankle, we have a lateralized pull of the heel cord. You have an overload of overuse of the lateral ankle. You have an overload of middle ankle ligaments and overstress of syndrosmotic ligaments. So when you have such a case, the question is, is that feasible? I think that the valgus instability, when you have a proper realignment of the ankle, we can achieve that with a tensioning of the ligaments and maybe osteotomy of the calcaneus. And we have an appropriate instability provided by the prosthesis. It will work, as you can see in this case. But is it feasible in this case, where you have a valgus instability and the deformity of the hand foot and the deformity of the hand foot that's even fixed? You have a middle ankle instability. I think it's probably not possible to do ankle prosthesis. As you can see, it was done here, was one of my earlier cases. And you see the results three years later. You have a recurrent middle ankle instability with unstable ankle prosthesis. So what do you say in the literature? In the early days, Peter Wood stated that we must be very careful and the valgus below five degrees may be possible, but all what is over that may be critical or even not possible. So be careful. Hagen Koffhut, almost the same time, he came up and said, limitations are far less. Maybe I can go to valgus of 10 degrees to be corrected with the implantation. And with that, it works. He said it can be handled. So what is my approach? When I see a case like a valgus ankle that is stable, we have a collapse here in this case of the ankle joint complex with impaction of the lateral pilotibial, but that's most important. The middle ankle ligaments looks like to be competent and there's no breakdown of the arch. So in this case, you see that's interoperatively and applying distraction to the ankle joint complex, you can see how the ankle, the hand foot becomes well-orientated and you can do the ankle replacement as you can see here. And after 10 years, we have a stable situation in this replacement ankle. So my belief is that the joint replacement may be successful because it acts as a spacer to tension the worn out ligaments. And with that, it stabilizes the whole ankle joint complex. And I also believe that the parallelism at primary and secondary interface of the ankle is important for restoring of instability stability and the frontal plane stability. What is now the situation, my approach in a valgus ankle that is unstable? As we can see here, we have a collapse of the ankle joint complex and we have a gapping of the medial tibial tail joint. So the medial ankle ligaments are not competent and we have some breakdown of the arch. In this case, you see it worked because I did here as approach all these problems, particularly the collapsed arch. What I've learned and you can see that here that when you leave some valgus, it may be stable over time, but we have a potential lateral overload and asymmetric at the ankle joint itself. And this ankle is at risk to fail over time. So the implications of the clinics are that the ankle prosthesis must reorientate the talus in the frontal plane and provide talus stability. And the ankle prosthesis with this may reorientate the calcaneus and provide stability of the calcaneus. Again, I think the ankle prosthesis may contribute to with the instability in this particular cases. Now, how is my approach in a valgus ankle with a collapse of the arch like you can see here, we have a valgus tilt at the ankle joint, we have asymmetric joint gap, we have breakdown at navicular cuneiform joints and we have dislocation with probably a spleen ligament rupture. Here you see the overall situation, also clinically the foot and you see the significant valgus alignment and to research with this rupture of the spleen ligament is confirmed. So in this case, we need to do first work to get this ankle stable and reorientated. So what I do is I do fuse, make a subtalar fusion as you can see at the lateral side, do a little approach, I make then a primary fixation by tensioning the ankle joint complex with the spreader to get the ankle joint tensioned. Then I see that it's not enough for the alignment of the heel. So I take out this primary fixation, I do the sliding osteotomy and then in this position, in one disposition, I do the subtalar fusion. And then I continue with the total ankle replacements to get a stable foot and you see here how it looks like. But at the end of the surgery, I have carefully to check the forefoot. If the forefoot is in supination because of a breakdown of the arch, I need to do major work. In this case, I did a navicular cuneiform fusion to get a stable arch. And here you see this ankle replacement was successful after 10 years because we have a good alignment and stabilization of the hand foot and the stabilization of the arch. In conclusion, successful of treatment is, for successful of treatment, crucial is to fully correct the deformity. The tools are arthritis, osteotomies and maybe ligamentoplasty. But I really feel that, and I learned, that we have to trust the bone in the valgus ankles and not the soft tissues. So if you tolerate some valgus, as in this case, you see, after two years, we have some valgus, the patient will come back because we will have continuous valgus deforming forces and the ankle may fail. So I think, and my conclusion is that in a valgus ankle, there is need for a meticulous assessment, clinically and radiographically. And we need appropriate techniques to stabilize the foot, the hand foot, to reorient it, to align the hand foot, and in particular, to stabilize the arch. Thank you for your attention. Yeah, thank you very much. That was excellent. I have a question for you before we move on. Do you ever stage these? Do you do a flat foot reconstruction and then do an ankle replacement weeks later? Or do you try to do everything in one stage? In most cases, I try to do it in one stage because I guess it's very difficult to do just one part. And without doing the ankle replacement in the beginning, you have no tensioning of the ligaments. That means the ligaments are still unstable and the talus will still tilt in the mortise. So that's not a good situation. So if ever the soft tissues allows to do it, I do all at the same time. I'd like to say to the audience that I have been combining a medial translation osteotomy with a subtalar fusion for about five years now. And it's an incredibly powerful way to manage hindfoot belgus. So I've started to do my calcaneal osteotomies percutaneous but I would encourage the audience to consider that option in the belgus hindfoot, even with pes planus reconstructions as it's an extremely powerful method of getting the calcaneus to sit below the tibia. So we will be going through cases and also have a discussion at the end. I would encourage the audience to type in your questions. Below you'll see a slot that says question and answer. If you type in a question, we will make sure to get to it or we'll do our best. I'd like to turn the podium over to Mark Easley who's gonna talk to us about total ankle replacement in the presence of a Taylor-Varus or pes cavus deformities. And particularly I'm interested in if Mark feels that tibial osteotomies are ever indicated in these scenarios. Mark, the floor is yours. Hey, you're still on mute, Mark. Yeah, can you see my screen? Are you able to see my screen? Yes, we can, Mark. Okay, perfect, great. Good. So I'm a consultant for Exact Tech. I just wanted to remind you, Tim, that the Carolina Hurricanes beat the Toronto Maple Leafs this week. Thank you, thank you. Yeah, good. So we know that there are ways, and you've done a great job with this, to show that we can correct these deformities with total ankle replacement. And if we can get it back to a neutral alignment, we can have successful outcomes. And there are several studies, some are short-term, some are longer-term, that show this. So I wanna make sure that we go with a basic principle. So we wanna, if we have a cavus foot or a relatively subtle cavus, we'll do some of what Beat just showed us, but the opposite. So we're gonna do calcaneal osteotomies that flatten the foot, we'll elevate the first ray, and try to get the foot tripod to sit more in a neutral position, or even a slight varus position. You can see here, I even did a tendon transfer, you can see the suture anchor, to take the longest to the brevis. And then if we have severe cases, we're gonna try to correct these cavo-varus foot alignment deformities and help us. So the plantar fascia may need to be released, the lateral structures may be completely incompetent, and we'll have to rebuild those, including ligaments and the peroneal tendons. I wanna emphasize this too, which I'm doing more and more, including an ankle replacement for these deformities, is a posterior tibial transfer. It is a deforming force, the foot will not collapse into valgus if I transfer this in a severe varus ankle, and I can make the lateral tendons much more competent. And there may be times I need to add a supramalleolar osteotomy, but like Beat showed nicely to create an arch, I wanna take the arch out, so I may need to do dorsiflexion midfoot osteotomies, like I did here in this case, where I did a combination of procedures to get a more plantar grade foot. And then I'll have to fix that, and it's a lot of work, and you can see the tourniquet has come down, trying to make this all do in one stage, just like Beat just showed us for these cases, and I can balance this ankle, but you can see that I worry about this a bit, because I don't have anything to stabilize within the ankle joint. So I'm with Beat that I think that the total ankle replacement adds a lot, but in this case, I was able to balance the foot well, but I have to apply these same principles to my total ankle replacement. So I do supramalleolar osteotomies, here's a case of how I do it. If I do it, I favor a dome osteotomy when I can. So here's a patient came to me, and we were talking about total ankle replacement, and I said, well, I could most likely do that, and that was my plan, but if you look at this, you think, sure, this would be a reasonable candidate, reasonable age, but there was the CT scan, so I thought I may not have good support for my ankle replacement, and so I bone grafted that, and then I did this dome osteotomy for him, and realigned him, you can see the technique here, and I'm realigning it, and it includes a fibular osteotomy, and there was some foot realignment done as well, so it's a combination of procedures to balance this, and at 18 months, he was doing quite well, but still, I think that at some point, I need to address the ankle, so Beat had a nice study, and I'll refer to you, Beat, many times, so thank you for all the great work you've done, but you showed that with these deformities, you can get a better alignment, and I like the schematics you had for the valgus ankle, with an ankle replacement, rather than supramolecular osteotomy, although supramolecular osteotomy in isolation could be successful, and so part of that is correcting the foot underneath the ankle, but, and again, we know that if we can get these deformities corrected well, then we can get equal results as we can with neutral alignment, but it is important to work within the ankle, too, so let's go through a few cases now of how to correct this varus ankle, so here's one, varus, and do I always need to do a lateral ligament tightening? Well, traditionally, that's what we've done, and we've protected the deltoid ligament. Well, I've learned, and I think most of us agree, that that, in a varus ankle, that's a deforming contracted force, so it may not be always necessary to do the lateral ligaments, and instead, we can do a medial release, and you can see this, even in this mobile-bearing ankle I'm using here, I'm gonna minimize my bone resection, and as much of the principles, just like Mike Murray had talked about, many of the principles on total knee replacement, so we're gonna balance this ankle well, but minimize bone resection and do the proper ligament releases in order to get this to balance just like we would in a knee, so even with this mobile-bearing ankle, I was able to balance this ankle without having to do a lateral ligament reconstruction. Here she is two years following, realignment along with the ankle replacement. Now, here's somebody who's a little bit older, same deformity, so again, medial release, lateral gutters cleaned out. I'm able to correct this. Again, I'm using a mobile-bearing ankle. This was a few years back, and you can see I'm minimizing the bone resection. Still, with that, I've got now medial and lateral looseness to the ankle. I'm gonna clear out what cartilage is left so I can try to promote more valgus to the heel, get the foot realigned underneath the ankle, and you can see here that I'm, not important with the steps, but I'm cleaning out gutters so there's no impingement laterally, and then I'm gonna balance this as best as I can, but that's not enough. I can't just rely on that release. I'm gonna have to do more, so just like they had suggested for valgus, for the varus, I'm gonna do a tendon transfer. I'm gonna elevate the first ray. I'm gonna also, don't ever do this. Don't do three incisions. That was not smart. I was lucky, but I'm going to tighten laterally. I'm gonna loosen, or fractionally lengthen in this case, the posterior tibial tendon so I can get that ankle better balanced, and you can see that here, and even though it may not be perfectly aligned for this mobile-bearing, the ankle is well-aligned, and he's done well over the years, but it's a lot of extra work. Now, what about if it's severe like this? Can I do total ankle replacement in these type of situations? I can still correct through the joint. If you look like what Cornelius Dutz did, he had a great study of mobile-bearing versus mobile-bearing, and he had, the most common complication was medial malleolar stress fractures, and so then a few years later, he came out with, why don't I just correct the ankle with medial malleolar osteotomies, and so I like that, and I think probably that was born out of the previous study that that may be one way to do it, so on this ankle that's tough to realign, I went ahead and did a medial malleolar osteotomy, and you can see here, instead of releasing the deltoid ligament, I'm gonna allow the medial malleolus to come down, balance. I'm doing lateral tightening with this, and this, I used a fixed-bearing ankle where I do intramedullary alignment, and not important so much, but even with all that, I still needed a larger poly to balance this ankle, and I'll take you through this. I went ahead and fixed the medial malleolus, and you can see here now the ankle's balanced, and as a reward, he had me do his other side. Now, here's one where there's a supermalleolar deformity, and I talked to this patient about, I might need to do a supermalleolar osteotomy to correct that and then do ankle replacement. It's all distal. It's not a proximal alignment. I think it's always important to look at the overall limb alignment. Don't forget to do that. Here's the arthritis. Here's the CT deformity, but I went ahead and did a medial malleolar osteotomy and combined it with a lateral malleolar osteotomy to get this ankle balanced, so I was worried at the conclusion of the procedure that I didn't correct it enough, but you can see here with follow-up, he has, that's valgus, not varus there. He now has valgus heel position, and he's done well, and that was just one year. He's been back to see me for 10 years, so do I add a supermalleolar osteotomy? Well, yeah. Well, here's a case where it is more severe, and I have to correct where the deformity lies, so you can see here, I'm doing a supermalleolar dome osteotomy, and there's the fixation. The difference from my cases where I do just a supermalleolar osteotomy is I have to move the hardware up more proximally so I can fit the prosthesis underneath that, so it's a slightly more diaphysial, metaphyseal osteotomy at times, so I can fit the prosthesis underneath, and here's follow-up of this example case. Here's another case where I had a deforming force here, and I corrected. I felt I did a good job of bony correction. I did a medial release, and I felt it was balanced, just like in a case I showed before. Well, it's not enough. It's not always enough, and there were times we have to do more. We can't just rely on the ankle and that soft tissue medial release without doing something laterally to correct. Here's an example I'd like to just show of this where I'm doing the ankle replacement. I've done a medial release. The components are in. This is my trial poly, but it's completely unstable, and so then I have to resort to doing a lateral ligament tightening. Now, I want to focus on one thing. When I tighten the lateral ligaments in a case like this, I take the poly out, and then I can get much more tightening of those lateral ligaments and scarred tissue there, and you can see I can downsize the poly then, and then what I have is I have a stable ankle there with medial release and lateral ligament tightening, so just a little trick. Take the poly out when you do this. Here is a more severe varus case, medial release and lateral ligament tightening. Very happy with it. He had some type of procedure before for his varus with that staple in the calcaneus. It wasn't enough. I just didn't do enough here. I needed to do something more, so how do I salvage this? Well, the components were stable. He had fractured his medial malleolus. If you see it, he has a little stress fracture, so I did a supramalleolar osteotomy. You can see here where that stress fracture is, and so I was able to do a supramalleolar osteotomy and with my dome osteotomy, and then here is the fixation along with fibular osteotomy, and once I had that, I also ran a plate down the medial side, then he had a stable ankle after realignment, and he has done well over time, so you can see that here. So it does take more, and often a supramalleolar osteotomy is important. Here's a case where there's post-traumatic deformity, varus malalignment. In this case, I did the supramalleolar osteotomy and the total ankle simultaneously. He's done well over time. So I'm gonna turn to Beat just to get some overview, and Beat, thank you very much for all of your teaching. Just to do some more algorithm, I started doing this and I said, my God, you've done all this already. So when you have these deformities, you could just put it in in situ. That probably won't work out very well unless you do some further correction. You've got to balance this properly, just like Beat showed, so I wanted to make that clear. So you could do a supramalleolar osteotomy to get this balanced, but you need the total ankle in there to do it. And Beat has these beautiful pictures and illustrations of his cases of doing the combination of procedures. So supramalleolar osteotomy balanced and then total ankle replacement, which contributes. And I'd like Beat at some time to comment on this osteotomy that you do here in addition to this. So it's different than the medium malleolar osteotomy that I showed for my case. So Beat, when you have time, I'd love for you to talk about this flip osteotomy or the additional correction that you do medially. And here's a case at 10 years where you've done great correction. Beat also points out you've got to remember to do the deformity correction where it lies. And even if this is diaphysial, you may have to take this higher to get a proper correction. I love this here. It's a very safe, long osteotomy, even though it's diaphysial, to get the correction. And then remember, it's also in two planes. It may be a two-plane deformity. And Beat, you've done a lot of study of this. And so I think it's really important to understand it's not just always in one coronal plane. And so you have experience with opening wedge osteotomies. I don't use those as frequently. I try to use a dome when I can. But the goal is to make it back to a normal ankle. And so I love these algorithmic thoughts that you've had. Here's a distal tibial dome osteotomy that you have. And then adding the fibula, you have to correct with the fibula as well. But then putting the total ankle replacement in is what allows you to get the stability as well. And that's important. So you can do it without supramalleolar correction, but you have to maybe do it with supramalleolar correction and with medial release, soft tissue release. And then you may also have to do further osteotomies of that medial malleolus. So you call it here a horizontal osteotomy or a flip osteotomy. So my question to you is, if you could just define how you use that and the fixation for that, because to me, it looks like that would maybe not be quite as stable as what I showed with vertical, but I want to learn. If the flip and turning of this and gets it in a better position, I certainly would like to learn. So, and you can also, I just, I talked about the posterior tibial tendon. So that means it's a deforming force. It has to be addressed. And then you've got to do the lateral ligaments and you have some examples of where you do this within the joint. For me, I usually make separate incision like you show here, where you rebuild that lateral ligament. I think that's important. And then you do the tendon transfers, just like I showed, peroneus longus would go to brevis as a better correction for the foot deformity. And so I use that same technique. And here, you can see that here where the tendon is being transferred. You also mentioned the Achilles tendon. I often work with the Achilles tendon to make sure I get the pull corrected. That really comes with that calcaneal osteotomy. I showed a lateralizing and superiorizing and lateral closing osteotomy, but your osteotomy, if you describe the step cut, Z-osteotomy has great advantage as well. So I wanted to make sure that was pointed out and here's that's being shown. And then if it's really a stiff hind foot, an arthrodesis may need to be performed. So I like that. So I just want to conclude with, here I am doing an ankle surgery where I'm releasing or fractionally lengthening the posterior tibial tendon, but transferring that posterior tibial tendon has really been a great benefit to me as well in doing the combination of procedures. This was described a while back, and I've used this in select cases too, when it's particularly severe, you can see this terrible deformity that maybe should be fused, but trying to give the patient the benefit of the doubt. So lateral gutter clean out, intramedullary type device, you can see I'm trying to correct this, but it's a severe varus, even with the release, even with releasing the posterior tibial tendon, deltoid has been released and it's just not stable enough. And so then I'll go and take the poly out and do the lateral ligament reconstruction like I showed before, I'll get that foot in a better position and then you can transfer the tibialis anterior tendon. Be careful with that, it has to be covered with the retinaculum, you could weaken the leg some, I would recommend doing a tendo achilles lengthening or gastroc slide at the very least, but you can transfer that as a deforming force as well, the tibialis anterior tendon, and you can see that being done here and then dropping the polyethylene in properly and the tendon transfer you can't see because it's done with a bioabsorbable anchor. And then the lateral ligament, rarely I've ever seen this, but it was actually pulled off the talus rather than off of the fibula, that's why the anchors are there. So not a full correction of the foot and maybe an arthrodesis would have been better, but he was able to function much better, but the tibialis anterior tendon still needed to be moved. Another question I'd have for the group as I finish here is fixed bearings, should we be using fixed bearings? We have, you've had years of experience using a mobile bearing and Tim and Mary, I'm sure you have too. And I showed some case examples too, but is it maybe better with these severe coronal plane deformities to have a fixed bearing ankle, or if I balance it correctly, can I use the mobile bearing ankles successfully as well? So that would be one of my other questions. I'll save this, Tim, for you. Maybe we can come back to this later. I have this case on Friday, two days from now. So I want your help on telling me how to do this because I don't know if my dome osteotomy is gonna work so well for this particular deformity. And I'll leave it at that, but thank you. That's great, Mark. And we'll come back to that case. Mark, there's a question in the question and answer section. I have the same question. Can you describe your medial release? Like how do you perform it? And where do you start and where do you end? Yeah, so my experience has been that I really don't have, I don't have a good way to do just a partial release. So it's gonna be a complete release. I just rarely, like in the knee, I gave me a total knee example. And what I used to do when I used to do knee replacement surgery is I would release the deep medial, well, the medial collateral ligament. So the deep MCL would be released completely. And then I would do this graduated release of the superficial MCL down the medial tibia. And so it was a nice procedure where I could gradually get the correction I wanted. With the ankle, I have not found that to be possible. So I put a knife inside of the ankle joint on the medial malleolus, it's inside, and I sweep directly on the inferior surface of the medial malleolus. And then I sweep up along the medial. So that's really the deep MCL equivalent or deep deltoid. And then I'll sweep along the medial side of the tibia up the tibia. So if you took the total knee principles and put them upside down. I'm sweeping up the medial tibia like I would for the superficial MCL, but this is the superficial deltoid. And that may include even all the way to the sheath of the posterior tibial tendon. But that's just with a knife. To complete it, I take a key elevator, put it inside the joint and run it directly underneath the medial malleolus all the way back to the posterior tibial tendon. So it's a very satisfying orthopedic procedure because it makes that kind of sound orthopedically. And that's when I do the release, but it's all the way around the medial malleolus. So the advice I would have to be more comprehensive, this is not going to suddenly collapse into valgus if you do a complete release, but it's not going to correct well if you only do a partial release. And a lot of the strongest fibers are all the way posteriorly by the posterior tibial tendon. And Mark, do you ever include the posterior tibial tendon as part of your release? Yeah, intentionally and unintentionally. I've pushed it back and I've certainly injured it, but I have intentionally, like I showed in one of the illustrations, I mean, one of the pictures, the photos, I have gone in and fractionally lengthened that. I've completely cut it, but like I was trying to emphasize, and sorry if I went a little too fast, but I'll make a separate incision just like Beat showed or had in this slide that I borrowed, and thank you, Beat. But I release it through a small, careful incision over the medial navicular. And remember, you have an incision anteriorly. You don't want to get a big medial incision because some of that deformity, if you do an aggressive correction in the valgus, you may have a soft tissue problem there. So it's a small incision to release it off of the navicular. And then I'll do another incision, just like I would for a drop foot surgery on the posterior medial aspect of the tibia, and then use that to transfer the tendon directly, immediately behind the tibia and the fibula over to the peroneal tendons. Now, they may not be very functional, but Beat showed, I showed some case examples of taking the peroneus longus and transferring it to the base of the fifth or to what's left of the posterior, I'm sorry, the peroneus brevis. And then what I can do is take the posterior tibial tendon and tack it into that tendon construct. So yes, you might think I'm going to get much more overpull into valgus. Even so, the foot and the ankle are not going to collapse in the valgus. It just doesn't happen, even though I've released everything medially and transferred the posterior tibial tendon. Thank you, Mark. And Beat, can you quickly describe your indications for that medial malleolar osteotomy? Yes. I'm scared about this poorly ligamentous release. What I do, I go on the edge of the tibial component in an angle of 45 degrees. I do the osteotomy and then I spread it with a laminar spreader. I open it and it's dramatically to see what happened. You see that the ankle becomes really stable or aligned. And in particular, what I do, I can do that from anterior approach. Then with my thumb, I push the medial malleolus down. So in an angular manner. That means the problem is what I see, that normally in a valgus ankle, I call that the horizontalization of the medial malleolus. And if you release, you have still the medial malleolus offset of the talus. With this tilting of the medial malleolus, I bring the medial malleolus back to the talus. And then normally is a little gap left. I put some, the screws first, and I put just some bone from the resection bone from the prosthesis that put in this little gap and they heal quickly. So after six to eight weeks, they are healed. My aftercare doesn't change with this, that's so stable. And in particular, the ankle looks better. And I think that's the problem when you don't do this osteotomy or the dots osteotomy with sliding down only, you have still this lifting off of the medial malleolus. And Mark, I feel even when you go for extended release, sometimes the nature scar back the ligaments. And over time, I believe that you have to risk that the talus goes back into valgus. Whereas when you do the osteotomy like I do, taking down is forever solve this problem. And the direction, the vector force of the ligaments now are in a different way. Do you think it's more of a problem with a mobile bearing ankle? Do you think a fixed bearing ankle would solve some of that worry that you have about releasing the ligament completely? Of course, that's advantage can hide the problem with a two component ankle. But in a three component, you cannot. Yeah, I learned how to balance the ankle with the three component for sure, because you can't rely on the prosthesis to have any constraint. Gentlemen, I'd like to remind you that in the question and answer section, there's specific questions, be it there's several questions specified for you to answer, same with you, Mark. So please visit that. In order to get through these topics, I'm going to turn the table over to Michael Bragi, who is going to talk to us about revision, total ankle replacements, tips and tricks, and when to bail with a fusion. Michael, are you there? Yes, you are. I am. Is this working? Yes. Okay. Thanks again for having me. I really appreciate it. This is my disclosure. I have received nothing of value for this talk. So how long do primary total ankles last? Murray gave us a nice presentation. I typically rely on this paper. It was a meta-analysis of 58 papers involving almost 8,000 implants. They used this statistical analysis. And what they found was that the overall survivorship of ankles was about 89% of 10 years with an annual failure rate of 1.2. So I give my patients 10 to 15 years, and then I think you'll need a revision. Indications for revision include impingement, malposition of components, loosening, pain, infection, and ligamentous instability. And then, of course, the problems you encounter are components subsidence, bone loss, coexisting adjacent joint arthritis, and hindfoot and midfoot deformities. And as we've already learned, it's extremely important to balance the foot and the tibia, especially in a revision. And I'm on board with everything that has been said in terms of tendon transfers, lengthenings, and ligament tightening. So I think it's very important you do this. I have a lot of custom total ankles that I deal with up here because my mentor put in thousands of these. And so here's what you can end up with after you remove a custom implant, a lot of bone loss. So let's talk about bone loss. There's large bone loss and minimal, and then your decision is either to fuse it or to revise it. And honestly, the decision to fuse is really up to the surgeon and his level of experience with this and what is best in his hands. I can say right now in my practice, I am able to revise a great many of these to a revision prosthesis using the modern systems. And I rarely have to fuse them. If the prosthesis can be salvaged, I suggest you try to salvage it. So this is a star that I put in in 2014. And it became painful after about four years. And you can see his periprosthetic osteolysis CT scan is always more devastating than plain film. So it's very, very recommended that you get a CT scan. But when we got into surgery, the implant was really quite stable. It was not loose. So we cure attached the cyst out and you can see with the freer elevator how enormous the cystic disease is. But I grafted it. In this particular case, I use calcium phosphate cement. I did do a poly exchange in the debridement and we did a revision gastroc recession. And then this is what it would look like at six months. You can see the bone graft is healing. This is him at two years. There's a little bit of polycystic disease, but at four years, he's still doing well, pain-free and stable. So you can salvage these processes. And if you can, I suggest you do that. Bone loss on the tibial side is what we just saw. This was an agility that could not be salvaged. And you can see again, the enormous periprosthetic osteolysis and the almost near pathologic fracture that's about to occur for this patient. So in my practice, I use this total ankle system to help me through this. You can see the tibial trays now are four millimeters, eight millimeters. So you have a lot of metal that you can replace the cysts with and you can build your modular stem to the needs of the patient. You have polys that range from six to 20 millimeters. And so you have a lot of metal to work with here to restore the tibia. And on the bottom here, you also have a tailored plate, which is very handy. If you have sufficient tailored bone left these are becoming three and six millimeter sizes as well. So you can restore the talus assuming there is enough talus to work with. So here is a revision case. You can see on the left that the polycystic disease has been completely resected with the InVision system. And we have a InVision tailored plate and bone down, a plate down as well. And we have a nice revision here and the patient is doing well. What do you do on the talus? Well, if you have devastating tailor loss there's really only two things that I know you can do. You can do a tailor rebar technique or you can use a 3D printed talus. So here's a case of a septic ankle prosthesis. This woman had two debridements and cement exchanges, six weeks of antibiotics. And my plan was just to brace her and weight bear on the cement. But she hated it. She said it was too painful and she didn't want a fusion under any circumstances. So I thought we'd give it a try. And so in surgery with the cement resected I start by laying down the talus and you can see that it sits okay on the AP but it's plantar flexed on the lateral. So I start using screws for support and I build those screws up until I get it balanced. And then this is the tibia has been put in and the talus is now resting on the screws and it seems like it's in good position. So we then used, we mixed polymethyl methacrylate. We put it down on top of the screw mass. Then we let the tailor prosthesis sit and we hold that until it cures. And this is this lady now at one and a half years. She's doing well. The prosthesis is amazingly stable despite the pathologic fibular fracture. And so you can certainly revise ankles of this nature with this technique. Here's a lady that had a star placed six years ago. She has severe rheumatoid arthritis but you can see complete collapse of the talus. And the CT scan shows practically no talus left a large cystic disease, both on the tibia side and the calcaneus and whatever talus is left. So we did a 3D printed talus on this case. You have to, you typically CT scan both ankles so that you can reverse engineer the talus. And so you do a webinar with the engineers depending on the company you use. And then in this particular case we imprinted a in bone tailor dome on top of it. And we plan to fuse the prosthesis to the subtalar joint. So screw holes are placed. And the prosthesis looks like this with an ingrowth surface plantarly for the calcaneus and the in bone talus on top. You get two of these implants typically. One is a little bit smaller, about a millimeter smaller than the normal. So you have two things to try. And I have not had an instance where I couldn't get either one of them in. So the case looks pretty much like this. You remove the talus, you line up your cutting block. You take as much tibia out as you need to remove the cystic disease. You place the tibial component in, you place the trials in and then place the implant in and fuse it. I take the tibial bone shavings and graft the in both ingrowth side on the other surface of the tailor implant. So this is her at four years. She is doing well. And she actually tells me that this is felt better than her star ever did. So that's amazing. A quick case on ligamentous insufficiency. I would do this for a lateral ankle ligament insufficiency case as well. But this was a 75 year old who had a sub-tailor and TN fusion in 2017. A star ankle placed in 2018 at deltoid ligament reconstruction in late 2018. And he presented to us and he's never been pain free. His obvious ankle valgus, he's pest plantus but he's kind of fused that way. It's not bad. He has lateral ankle pain from impingement. His sed rates are normal. He's a non-smoker. CT scan shows no real per prosthetic osteolysis but shows the valgus orientation. So I staged these. I have had great success doing this. This is an interoperative stress X-ray. So we can see the implant reduces. I did a calcaneal medial sliding osteotomy to get the heel under the tibia as already discussed at length. I put a cement spacer in after removing the implant and I hold that until the cement cures. Then I do a double limb allograft deltoid ligament reconstruction. And then I wait for several months to let that all heal up. And this is him at two months. And you can see his alignment is much improved even than his opposite side. In surgery, the cement spacer is removed. This is a stress X-ray showing the tendon, the valgus, the tendon reconstruction is doing well. So this is now just a regular in bone two replacement. Tibia in, talus in. This is him at three months. And he recently came in for his one year evaluation doing well and motion. So I would do that as well for lateral ankle ligament instability. I would do the same procedure. When do you fuse it? This is again, based on your experience and preference. I fuse it when it's an unreconstructable deformity, if there's severe bone loss, if it's severe osteopenia or osteoporosis. And some patients just have had enough. How do you fuse it? There isn't really a great technique. This is a femoral head allograft technique that I'm sure that we all are familiar with. But the fusion rates are really a hit or miss. In these two papers, you can see here, the fusion rate was only 58% in Roy Sanders' group. And the fusion rate was only 48% in Mark Meyerson's group. These are both great surgeons and these are tough, tough cases. How about a cage? Well, they recently did a meta-analysis. This is out of Duke and their cage fusion rate was only 50%. But here is a case that I could not reconstruct. This is a lady with rheumatoid arthritis with a severe flat foot and a failed star, which was subsided. CT scans show severe deformity and probably a well-fixed implant, but she had a custom cage fusion. So this is the ankle debrided. The trial is in place on the right. We had to straighten out the cuts a little bit freehand. With the cages put in, K-wires are going through the cage for accumulated screws. The screws go in. I reinforced it with a plate anteriorly. And then I also did a calcaneal slide. And here's her at six weeks and at 1.5 years. And you can see that the tailor, one of the tailor screws backed up a little bit, but she's doing well. And at two and a half years, she just came in and nothing's changed. Do I think it's fused? I don't know, but she's doing well and I'm not gonna really go looking for a reason to operate on her again. So in summary, modern total ankle systems can be successfully revised and a variety of bone defects can be addressed. And arthrodesis after a failed total ankle continues to be challenging. Thank you. Thank you, Michael. That was excellent. And you're a brave soul. You've given me some ideas, including one of the cases I was gonna present. So I'm going to quickly go into my video and maybe take five minutes on this, and then I will turn it over to cases. And Mark, if you can get your case ready, we'll go through that case with you. So I'm just... Okay, my video is... Can you guys see my screen? I see it. But the... Okay, now we're settling down here. So this is a vast majority of patients that come to see me that want their ankle fusion revised. Our patients that started off with a cavel varus deformity have been fused in a little bit of a Aquinas and they're not only unhappy with their stiff ankle but they also have a forefoot driven type cable varus deformity with overload to the midfoot and the plantar aspect of, or sorry, the forefoot break. So in these cases, I feel that not only do you need to mobilize their ankle but you need to correct the pes cavus deformity. I'll show the x-rays on this briefly but in these takedown fusions, what I do before I do any osteotomies is that I stabilize the medial lateral malleoli with hardware, be it screws or plates and then I develop the gutters. So here you can see that I've done a lateral incision. I don't, in my hands, I can't do this through the anterior incision. I'm placing a 3.5 by 70 millimeter screw right up the fibula. I don't hesitate to put on a plate but I felt a screw was enough to protect this malleoli. I feel that hardware in the malleoli is essential to prevent fracture. This lady was a very small lady and really was at the upper limits of the smallest implant. My disclosure is that I do, I am a consultant for Smith and Nephew and I do get royalties from the cadence ankle. So I've stabilized the fibula with a screw or plate. I've released the lateral gutter under fluoroscopic guidance. Releasing the lateral gutter, you have to be careful because the fibula goes posterior. So when you're taking your osteo curets, obviously the easiest conversion is if the lateral gutter is preserved. But if it's fused, you have to make sure you understand the orientation of the fibula and you need to do the release from anterior to posterior in the lateral gutter. Now I'm exposing the medial gutter itself and I'm getting it prepared. In this case, there was still, there wasn't a complete fusion of the medial gutter. She still had a little bit of joint space medially and I'm preparing that. I'm looking at it fluoroscopically. I just use a needle. You can use a K wire, but I'm identifying the medial gutter fluoroscopically and then I'm mobilizing it with osteotomes, curets, whatever you need to mobilize the medial gutter. Here I've chosen to put up a screw, again, a 3.5 by I think a 60 millimeter screw on the medial side. But because this lady was so small and I knew that I'd have limited bone medially, I decided to place a plate on the medial side before I proceed with the takedown of the fusion. So here we're putting on a plate. You have to understand if you're putting hardware on the medial or lateral sides, you can have a tight closure anteriorly and you need to adjust for that. But I've put a medial rectus plate over the medial malleolus. And then now I'm taking down the ankle. So I've got my gutters prepared. I've got the malleolus stabilized with hardware. In this case, if you look at the lateral floral, she's fused in plantar flexion and you have to be very careful with your cut because if you can cut through the back of the talus into the subtalar joint area, and particularly if you're using a flat cut talus, you will be into the subtalar joint posteriorly if you don't compensate for that plantar flex talus. So I'm putting the jig on, making sure that it's an appropriate position. I'm making my proximal cut just above the original ankle joint. So I'd say about a centimeter or two above the original ankle joint. This is just confirming the location, making sure that I've got the proper orientation in the sagittal plane. And once again, I'm paying attention to the posterior aspect of the talus, making sure that I'm leaving enough bone stock there because that is one mistake you can make. And that is cutting too much off the posterior aspect of the talus and tibia. So now we're preparing the gutter further with drill holes. This is just a technique that's used with the cadence ankle and I'm performing my first tibial cut. You'll notice that when I do this cut, I have a hand on the back feeling for vibration. You will not dive with that blade if you've got your hand back there feeling for when you're just coming through the tibia, you'll feel the vibrations as you get close to the back of that tibia. And as long as you're not plunging, it is a safe cut to perform. Now, I decided to leave the tibial cutting guide on because I wanted to maintain that gutter space and possibly use some more drill holes. I'm making sure once again, that I'm not gonna be taking off too much bone in the posterior aspect of the talus. And I'm making my second cut, which is about, I'd say 1.5 centimeters below the first cut. I'm still going to fashion this afterwards. The reason I use the distal tibial cutting guide is so I could put those pins in to protect the malleoli. And then once again, with my hand at the back of the tibia, so I can feel the vibrations of the saw blade as I start coming close to the posterior aspect, I make the second cut and then remove the tibial cutting guide. This is just a technique that I like to use. I like to basically create a Rubik's cube with regards to the tibial bone. Right now, I'm just using the lateral chisel to create the medial gutter and to release the bone on the medial side. And then I just take an oscillating saw and I create what I call a Rubik's cube with the oscillating saw and then remove the tibial bone. And I do this with all the tibial bone resection. I find it's the most rapid way to do this. Now, I'm very, very careful in mobilizing this ankle. You can see there's almost no motion there. So I've got a lot of work to do, but it's done very carefully. That lateral x-ray shows how the anterior aspect of the tibia still needed to be resected in order to get a flat cut on that tibia. Now, I'm gradually releasing the posterior structures with the laminar spreader. And this release took me at least 20 minutes. It's done very carefully. Most commonly, the last area that you need to release is the posterior medial aspect on the medial side. I'm actually taking a saw and recreating the medial gutter further with an oscillating saw. And then I will go back with osteotomes and carets and release that posterior medial corner because that's where they tend to be stuck down. Now, when you look at this ankle, there's very little bone on the medial side. That plate saved her. And I'm gradually mobilizing this more and more. There, I'm taking the caret to the posterior medial corner where there seems to be some bone and overhanging osteophyte type formation. I'm taking a thin chisel to release that. And you see that gradually, I'm getting more and more motion in that construct. Once I'm satisfied, you don't have to get a lot of motion here, but I'd like to get at least 10, 15 degrees of motion before I start putting in my ankle components. In this case, this case was done about two years ago before the flat cut option was available on the cadence. For all the takedowns that I use now, I use the flat cut option, but I will prepare the talus here through a standard technique with chamfer cuts. And I won't bore you with that part of it. Now, once I've got this trial components in, I've done a tendochilis lengthening or a HOC release of the tendochilis, which really helps give the final amount of motion that you need to give them a functional ankle. In these cases that are tight, I put the tibial component in by hand and then add the impactor at the end. There's her ankle replacement. And you'll see that at the end of this case, I think I show a range of motion, but I actually get a fairly functional range of motion with this revision. I believe, I'm just showing the closure here. I think closing and opening are extremely important in ankle joint replacements. You need to be a plastic surgeon when you go in and a plastic surgeon when you come out because it's extremely important with regards to wound healing. Now, I'm just gonna quickly show the x-rays of that case and then Mark, we'll go on to your case. So this is her preoperative x-rays. You can see that she's fused in Aquinas, but she also has a forefoot driven cable varus deformity. The most common reason I see people come for revisions of their ankle fusions is because the surgeon did not realize the extent of their cable varus deformity before they started their procedure. And this is the end result. There's her preoperative x-rays. You can see she's in quite a bit of Aquinas, but she's also got plantar flexion of her forefoot. And at the end of the procedure, she's got almost a neutral foot. I did a dorsiflexion osteotomy through the first metatarsal to decrease the forefoot Aquinas. She is now two years out. The main reason she wanted a mobile ankle is so that she could ride the horses properly. She couldn't fit this foot into the stirrups without some motion in her ankle. And she's back to riding. Mark, you can put your case up and we'll discuss it, but she's back to riding her horse. And I have to say, she is extremely satisfied. Most of these patients come, I get to know them. I've seen them for a year or two before I start on converting them to, or talking about conversion to an ankle joint replacement. Mark, you just have to get off that slide, please, young man. Anyway, so that's how I take most of the ankle takedowns. That's how I do it. Bottom line is stabilize the malleoli, create the gutters, do your cuts, mobilize carefully, get your component in, release the tendochiles. Over to you, Mark. Yeah, sorry. I just can't make it move, Tim. This slide just, I'm frozen on it. Yeah, I bet you are. Sorry. Mike has the kraken now, the kraken in Seattle. Hey, so this is a case, and again, I'm sorry, I don't have any follow-up, but maybe if we ever do a webinar again, we can. My question here was, I mean, I know how to do these operations, but to the group, I just would be curious, what type of osteotomy and what sequence, like Murray, we haven't heard from you for a while. How would you tackle this? I have to do this Friday, so I need quick advice because I only have less than two days. You do need quick advice because we're running out of time here, but yeah, this is, I mean, obviously this is a challenging one. I think you'd show it a couple of different techniques. I think each of us have our own way to want to sort of straighten these out. I think that the coronal plane deformity here is substantial enough that I wouldn't, in my hands, I'm not going to look at doing this as a one-stage with an ankle replacement. This is going to get a two-stage realignment and then total ankle down to the second stage. I think you can do this in different ways. It's primarily a coronal plane deformity. You kind of measure out where the core is. I think a lateral closing wedge osteotomy would be a very reasonable option for this. The catch with that is that you would shorten the limb a fair bit. You'd mentioned that you didn't want to do a dome. I actually think a dome osteotomy would be a pretty good option here as well. And then there's an oblique planar osteotomy that I think the only place I've ever seen it described was by Ted Hanson, but it's basically an oblique osteotomy in the semi-coronal plane that you can then rotate sort of on face and do that as well. And you can achieve huge correction with that. And I've done that for ones that looked almost exactly like this. So what would I do? I'd get a CT scan, look at it sort of in 3D and make a choice between those options. But I'd most likely wind up still with a lateral closing wedge here, depending on what the length differential would look like. Any other thoughts? Viet, what are your thoughts on this case? Yes, I would do the same, but just consider the informal correction afterwards. You may result in a valgus deformity of the hand foot, particularly the subterritor joint is not mobile. So in this case, you may add afterwards an informal correction as well. Okay. Thanks. Hey, Tim, one other question that came up that we should answer. Do we still do ankle arthrodesis or is everybody just do total ankles? I know Mike showed some nice revision cases, but do we still do primary ankle arthrodesis? Absolutely. And, you know, this webinar is focused on total ankle replacements, but ankle fusions are still a very important part of my treatment regime. And I would say that, you know, given the type of practice I have, I'm doing more replacements than fusions, but I still feel that fusions are a reliable assert operation that I offer patients, particularly with indicated. And Murray, I found your talk extremely interesting because in the last two to four years, when I've gone to any total ankle talks, I'm starting to hear people say that they don't consider age any longer, just like with the total knee. They look more at whether or not the patient has primary ankle arthritis or ankle arthritis with a periarticular disease. And most people that are doing more than, I'd say 10, 12 ankle replacements a year are leaning towards looking at the pathology and applying the appropriate procedure based on the pathology, as opposed to focusing on the patient's age. Murray, what are your thoughts about that statement? Yeah, I mean, I think, so I look at the age as really the surrogate word we use for multiple revision risk, right? And so we now have good techniques. Mike did a great job of showing us. We have great techniques to revise failed total ankles, even badly failed ones. But if you're putting somebody in a position of needing multiple revisions in their lifetime, we don't have good information on that. And so I still think age, because it is a representative of that, is an important part of this. Now, that being said, every case is individual. I just did a patient in his late 30s just this week. That's very young for me, but there's a whole bunch of discussion and sort of context that goes into a decision like that. But I think age is still a very important factor. And as you drift into those younger age groups, it's not an inappropriate thing to consider, but boy, it takes a lot more discussion when you are exposing that patient to inevitably needing multiple revisions, not just one. Murray, if you have a patient where you're looking at a pan-Taylor or TTC fusion versus an ankle replacement and periarticular work, what direction is your compass leaning? Do you, you know, and let's not consider anything about age or comorbidities. Where is your compass tilting on those? Well, I really, I steer my patients all now. Notwithstanding what I just said about age, as long as we're in a reasonable age range and we can bat that one around a bit, I tend to steer almost all of my patients toward total ankles now, which if for anybody who's known me for a while realizes that that's a fairly big shift for me. And, but particularly those with COFAST type three and four arthritis with either stiff hind feet or significant deformity, I think our data has shown fairly clearly that they do better with retention of ankle motion. They are tough cases quite often, but those are the ones that really gain the value of retaining ankle motion. So I will tend to be much more liberal with my indications for ankle replacement in those categories. Mark, we have two minutes left. Can you answer that question succinctly in 30 seconds? Sorry, which question was it? In patients with deformity or peri-Taylor disease combined with ankle arthritis, is your compass leaning towards multiple joint fusion or total ankle replacement with fusion below the ankle? Oh, total ankle, the latter. Okay. Total ankle replacement fusion beneath the ankle, yes. Be it, what are your thoughts on patients with deformity or peri, not isolated ankle arthritis, but multi-joint arthritis or deformity with ankle arthritis? Do you lean towards an ankle replacement or are you doing fusions? It depends on overall situation. Normally, I tend to go for an ankle replacement because to a Pantella fusion with TTC fusion is horrible for the patient. But if it's not possible because of soft tissues or diabetes or whatever behind, then I go for a TTC fusion. Michael, in your practice? Yeah, I'm like, I'm with Mark easily, pretty much same ideas. So we are one minute away from our time. Mark, thank you for suggesting that we increase this webinar to 90 minutes. This is a huge topic. I hope nobody leaves this webinar thinking that ankle joint replacements are the only option for treating ankle arthritis. Having said that, it certainly is becoming a accepted option. It is, I believe, a new standard of care and most patients with ankle arthritis at least need to have a discussion about ankle replacement versus fusion when coming to the decision of which direction to proceed. Gentlemen, this has been incredibly, it's been very knowledgeable for myself and I hope for the audience. And I'd like to thank you all for participating, be it, especially you. I know it's 3.30 in the morning, I think, for you. So please get some sleep before you have to fix those crooked ankles tomorrow, okay? Good night, everybody. Great job organizing, Tim. Thank you for including us. Thank you, everybody. Good night. Thanks, Tim. Fantastic job. Thank you. Have fun. Thank you. Great job. Bye.

ankle deformities

surgical options

ankle replacement

osteotomies

valgus ankles

pes cavus deformities

supramalleolar osteotomies

lateral ligament tightening

individualized treatment plans

dome osteotomies

ankle fusion

ankle arthrodesis