just quickly go through my conflicts. I don't have any direct ones, I think, with this talk. And I'm going to just sort of quickly outline what's happening with our province, because it's like, what's happening? Are we replacing more than we fuse? It's a primary question. We have 5 million people in our province, just north of you here. We have about 22 foot and ankle fellowship trained orthopedic surgeons. And we have one teaching center, but we also have one billing agency. So we're able to track our procedures. And so this is what we're doing. And so your question is, are we doing more replacements? And the answer is yes. So replacements are the blue lines. We did no replacements in 1998. And then this is where we're at now, doing roughly 80 to 90 per year in our province. But the number of fusions has also come up. And we also have a fee item for revision total ankle. And what's encouraging is that the ankle joint replacements are not being associated with an increase in revisions. So our access to care has almost tripled since the 1990s. And it's an indication of advocacy for our patients through publication. And when we look at the ratio of replacements against fusions, we can see that we did no replacements in 1998 in our ankle arthritis surgeries. And then replacements have stayed steady as about 40% of all ankle arthritis procedures since about 2004. So there seems to be a bit of a steady state here. And encouragingly, this is the ratio of primary to revision. So our early ankles required revision, but as we've gone on, our later ankles do not require revision. So why are we going to continue to see fusions around? Well, when you do a fusion, you only can make 12 errors in placement, two planes of translation, sorry, three planes of translation, three planes of rotation. But there's 50 errors you can make in an ankle joint replacement. So there's the same number of errors in position of each component, the relationship of each component, and then four errors in sizing. So the question is, is this worth it? In an ideal operation, we do this surgery, they get an immediate good outcome, and they maintain that outcome. But in fact, we often are mitigated by our reoperations. And so the reality of the patient experience kind of looks more like this. And so defining reoperations is important. So when we collected our data in Canada, we started in 2002, we had to work out how we actually talked the same language when it came to complications, you know, primary outcome measures, you know, such as using PROMIS, or we use ankle osteoarthritis scale is much easier than actually sorting out how we use terminology to describe adverse events. And so complications are hard to define, include things like DVT or wound infection, and reoperation is easy to define. And so that was one of the things that we wanted to actually understand when we collected data. And this is information that then was carried on to the TAVA study. A reoperation is likely an indication of failure of the primary procedure if it's in the primary site, it's costly, it has negative impacts on the patient, might be prevented by improving our design, or our primary surgical technique. And so they usually sort of all listed together in complications and outcomes research, but they're hard to define, and they have a threshold effect. So this is just a paper we did early on on the inconsistency of terminology. And we found when we looked at all the papers on ankle joint replacement, we found these multiple different terms, they're all kind of similar, but not the same. And we found 572 different terms available, and 320 were only used once. So we then came up with a coding system for revision surgery to compare ankle replacement and fusion. And we came up with this sort of 11 point scheme. And it forces people to actually choose an adverse event or complication. And so when we look at our experience here, this is about 2014, we see a relative comparison of repeat surgery. So we had 70% of total ankles not having revision surgery and 86% of ankle fusions not having revision surgery. But the revision surgeries were different and the impact changes. We had 11% revision of metal components, and eight of fusions undergoing revision for non-union. And equivalent rate of amputation in both groups of about 1%. So the reoperation classification system was reliable, and it allows us to compare results. This then resulted in a recommendation from the Foot and Ankle Editorial Board. So if you're going to publish on ankle joint replacements, you need to use this scheme so that we're all talking the same language. This is a paper that we published looking from the database, looking at isolated ankle arthritis. So no deformity, one ankle joint replacement design, and no surrounding joint arthritis. So the purest form of arthritis and the purest way of comparing the operations. And essentially, we had 88 integras, 50 arthroscopic fusions, and 100 open ankle arthrodesis. And what we found was, in sort of brief summary, that there was a difference in outcomes between these groups, but that the ankle joint replacements and the arthroscopic fusions did well and outperformed the open ankle arthrodesis, both in pain score and in total change score in outcomes. So the important thing is that not all fusions are the same, and that you may get better results if you do an arthroscopic fusion. And if you've got isolated ankle arthritis, you might be equivalent if you do an ankle joint replacement and an arthroscopic fusion and an open fusion underperformed. So if we're comparing this question, we have to be specific about what form of fusion we're talking about. We also found that at this time, there was a higher rate of repeat surgery, and this was more related to the total ankles. But if you go back to that original slide, and this is something we need to look at again, our current designs may be much less prone for ankle joint replacements, may be much less prone to revision surgery. So it both reduces the impact on the patient and outcome scores, but also reduces the impact on the payer. So this was our initial study, including all patients, published by Tim Daniels in 2014. And in this, we looked at end-stage ankle arthritis. And this was, again, a database series, so it's not an RCT. The benefit of a database series is it allows us to include all ankle joint replacements and fusions, but it's not controlled. So we're able to look at outliers that are often excluded from an RCT. Older designs in this study, and the mobility was actually dropped during the course of our studies, and was actually dropped just before the TAVA study. The fusion technique was patient-surgeon preference, and we used the ankle osteoarthritis scale. You know, if we could go back, we'd probably use PROMIS, but that wasn't around when we started. And we looked at the pre-op score, and then the final score at most recent follow-up. And we did include the revision patients in this. So in this particular study, we had 366 replacements, sorry, 267 total ankles, 99 ankle fusions. The pre-op scores were about the same with both pain and disability. And then the PCS is a less valuable instrument. Our revision analysis showed at this time that the ankle replacements had a cumulative revision rate that kind of climbed, and ankle arthrodesis had a fairly early and higher revision rate, but then it remained fairly flat to the eight-year time point. And there was differences in the ankle scores. If we looked at the crude scores, total ankle did better. But if we then adjusted it for age and sex and other factors, according to the advice of our statisticians, the effect was much less. So we concluded that mid-time ankle fusions and replacements were equivalent at this time point in 2014, but it may not be relevant in more updated studies. And this is actually still summarized in the TAVA study. Bruce St. Georgian has also published on this from Seattle. And he concluded in this paper in 2020 that there was better functional outcomes in the total ankle arthroplasty group. So as we get into more recent papers, we tend to see better results. But this step activity, which Bruce was very excited to try and present, didn't show a difference. So coming on to this paper, the TAVA study, which was done in the United Kingdom, is a really outstanding study. It is the benchmark now for comparing ankle fusion against replacement. And it is a large randomized prospective study. They obviously compared end-stage ankle arthritis, fusions, and replacements. So they also based their data and their design on the various publications that have been performed previously. They used three different designs, mobile bearing and fixed bearing designs. And they used endpoints as outlined in the national registries before. One of the problems is that national joint registries have many replacements in it, and only 1% of total ankles. Again, they use these two papers, which we've already discussed, as part of their design. So it's a randomized multi-center non-blinded prospective parallel group total ankle arthroplasty versus replacement study. If you note here, the funding was significant. It was almost $3,000 US, sorry, $3 million US to do the study. And it shows the amount of work that's required for us to get really good information. It was multiple centers across the United Kingdom. This is one of the TAVA meetings, so many meetings to monitor this study and design it. Their actual design is published in these two papers, and they were randomized if they were considered to be equivalent for both treatments to one or the other. And if you ever want to explain to patients the difference, go to the TAVA website. It's a really great resource. So they included those obviously with end-stage arthritis, and there was a number of exclusion criteria, including significant periarticular arthritis. The primary outcome was the Manchester Oxford foot questionnaire, which is a sensitive instrument, and they had a number of secondary outcomes that were included. The flow chart just shows exactly how they enrolled, and the main thing, the results. So it was similar baseline characteristics, which is sort of a control features. We expect them to be the same in a randomized prospective study, and that's essentially what they had with regard to both ankle joint characteristics and patient comorbidities. And the baseline outcome scores were the same as well. So that's a good sort of indication that there's good control. The surgical characteristics were much the same, but they did enroll almost 50-50 fixed bearing and mobile bearing ankles, and this became relevant when we look at the results. There's an equivalent number of other surgeries done at the same time. So the big message, what was the result? Well, there's a tendency towards the total ankles to be doing better and a slightly better improvement. And if you compared all, there wasn't a difference, but when we broke down or they broke down total ankles of mobile bearing versus fixed bearing, the fixed bearings actually had a significant improvement compared with fusion and compared with the mobile bearings. So again, bearing out that our total ankles may be outperforming our fusions at this point. Various outcome measures that were also studied showing some differences and range of motion obviously was better in the total ankle. Adverse events were similar, unlike our study, and basically equivalent. Obviously, we can look at things like systemic such as DVT and then reoperations, which we've discussed, which were very similar in their series, but this is only going out to two years, so we have to bear this in mind. The fixed bearing versus ankle fusion showed a difference, and therefore it matters what type of ankle joint replacement you're looking at. They also did a cost analysis, which is very relevant to payers, and they showed that there was essentially equivalent improvements in quality of life measurements. So I've given you a really quick summary of the TAVA study, I encourage you to read it when it comes out and gets published. It's really a fantastic study and is really beginning to answer questions well. So in conclusion, the TAVA suggests that both total ankle and fusion do well. It suggests an advantage to fixed bearing total ankle. We don't have an answer for those under the age of 50 and don't have an answer for those that met the exclusion criteria, which is a limitation of randomized prospective studies and why we need both randomized prospective studies and registries to address the question. So to summarize where we stand in outcomes at the current time, total ankle arthroplasty appears to be beginning to have better outcomes in ankle fusions. Complication rates are coming down in total ankle and becoming similar to ankle fusion. Now there's different information collected through registries and RCTs. They both have a role. Good data requires funding and strategy as TAVA has outlined. And the plug I've got is support AOFES and the research committee so that we can continue to do research like this. And I'd encourage anyone to study their, your ideas and your grants and donate to the foundation. So with that, I'm going to hand back to Hodges and to my colleagues here. Absolutely fabulous. And in such a short period of time, I think you brought us up to date and what's been going on. And I constantly, every time I give a talk, I shout out your group that has really been collaborative and given us so much information, but also clearing up the way we talk about it, which I think is challenging to this day, but getting better as we get on board with what you all set out to do. Sam, do you want to get up? So Sam is going to talk about his indications between replacement versus fusion. And you have to remember he lives in upstate New York. So no, he's got farmers and everything else in between, but I look forward to hearing about it. So Sam, take it. Hi, everybody. Well, thanks for having me. I greatly appreciate it. I have no disclosures. So I think we just heard from Alistair about why we should do total ankles. And there's a question, do we have better function and probably some preservation of the surrounding joints, but eventually they're all going to fail if you live long enough. And the attitude, if it fails, we'll just fuse it. These fusions are significantly harder to get. They're more difficult on the patient. And so we have to, we have to be reasonable about who we're going to put a total ankle in to start with. And so, when you look at my indications, well, my first indication is they should have end-stage osteoarthritis. You shouldn't be putting these in people just because they have an OCD. You know, that's a centimeter or so. I think they should have pretty significant arthritis, and it helps if they have some hindfoot arthritis as well. I think it increases your indications. But what other factors do I look at? Well, you know, I look at age. Are they too old? Are they too young? Do they weigh too much? Do they have too much ankle deformity to start with? Do they have foot deformity already? You need to consider that. Do they have deformity of their tibia? So, do they have deformity above or below their ankle? What's their range of motion to start? And then, what type, what are their comorbidities? Do they have rheumatoid disease, diabetes? Do they smoke? How is all this going to affect them having a total ankle replacement? So, if we look at some of the literature that starts with, and we'll start with age, and I think what Alistair showed is that, you know, the literature we have is getting much better, and most of these studies I'm going to show you, you know, have some flaws in their short-term follow-up, but this study by Easley and colleagues in 2015 looked at 395 patients. They had only three and a half year follow-up, but they broke them up into three age groups, 55, 55 to 70, and 70, the largest, greater than 70, the largest group was 55 to 70, and they couldn't find any difference in outcomes based on age, no difference in wound problems, reoperations, revisions. Another smaller study with only 41-month follow-up, two groups, so they had 31 patients. They did it in less than 50, and then a larger group of greater than 50, and again, no difference in complications or survivorship. Some other studies in mean age, 54, 87 mobile bearing implants at 15.5 years, 76% survival rate, age was not associated with early failures. Study by Daniels, 11-year follow-up, or nine-year follow-up in 111 patients, age 61, so fairly young for a mean age, 12% revision rate, but age was not associated with failure. I think one thing about age, though, you know, if you have a total ankle at 50, okay, so it doesn't fail any earlier than if you have one at 70, but it's still at 50. If it fails at 10 or 12 years, you know, you're looking at trying to do something at 60, and then maybe again 70, so you have to consider, you know, are there other alternatives for patients who are younger? Obesity, a growing problem, no pun intended in our country, at least. So, we go by BMI, so what is an obese BMI? Well, if a 5'9", 205-pound male, just so happens to be me, would have a BMI of 30 and be considered obese, and if I gained 70 pounds, I'd now have a BMI of 40 and be considered super obese. Likewise, a woman who is 5'5", 180 pounds is considered obese with BMI of 30, and if she gains 60 pounds, then she's going to have a BMI of 40. So, this is New York Giants running back Barkley. He's obese with a BMI of 32, just so you keep that in mind. So, Daniels, again, looked at patients with BMIs greater than 30, and 10 of these patients were greater than 40, a little less than four-year follow-up, compared them to a group of patients, of 48 patients with less than 30 BMI, again, about four-year follow-up, no difference in complications or revisions, outcome improved in all. Another study, 123 patients with BMIs greater than 30 still found survivorship at six years and 93% improvement, overall improvement in pain and function. Gross, even larger study, 266 patients less than 30, BMI 116 greater, or 30 to 35, and then 73 greater than 35, and all less than four-year follow-up. They noted obese patients had lower function, but overall, as a group, pain, overall functional improvements, revisions were all the same. So, they didn't really think that obesity mattered all that much, that obese patients just didn't function as well. Haddad had a little bit different take, looking at 49 patients less than BMI, or less than 30 BMI, and 48 with greater than BMI, pretty mid-term follow-up, seven to eight years, found obese patients with primary osteoarthritis had increased risk of failure at five years. In this study by Penner, this is my favorite, 145 patients who were obese at the time, followed them at six months, two years, and five years, they either had a successful total ankle or fusion. What they didn't have is a change in their BMI. So, when they tell you that, you know, if you fix my ankle, I'm going to lose weight, it probably is not going to happen. What about pre-existing disease? So, it's generally felt that if you have significant foot deformity, that should be corrected before you go ahead and put in a total ankle. So, this patient had a malunited triple arthrodesis, had valgus at the ankle. So, we went ahead and corrected her foot deformity, which actually improved her ankle deformity as well. And then we were able to go back in and put in a total ankle. But the point is, is you really need to correct the foot deformity before you put in the total ankle. So, you have to look at what the foot is, foot is like not just the ankle. And Dr. Lee is going to talk about this, but he's put out two excellent papers showing good outcomes with up to 20 degrees of varicervalgus deformity at the ankle itself. And then a year later, put out another one looking at greater than 20 degrees of deformity. And again, good results in these patients. And I'm sure he's going to give us details on that. Tibial deformity, you have to look at the whole patient. You got to look at it at least from the knee to the ankle. Patients have a lot of tibial deformity. You need to correct that deformity before you consider putting in a total ankle replacement. What about our preoperative stiff ankles? These patients, they come in, they have a lot of deformity, they're all socked in, they hardly move. Well, this recent study by Ruiz looked at 357 ankle replacements. They looked at their preoperative motion, their motion at one year post-op and at their last follow-up. They found that the total ankle replacements had no significant increase in range of motion from pre-op, but patients with lower range of motion had the worst pain, and doing tendo-achilles lengthening didn't seem to help very much. So you have to consider how stiff are these patients to start, and can you do things to improve their stiffness? Then we start looking at comorbidities. One of the first is rheumatoid disease, and what do we worry about with rheumatoid disease? Well, we worry about early loosening of the components, and then what I worry about most is wound healing issues. A study by Peterson in 2014, JBJS, had 50 patients with rheumatoid disease, 50 patients without. They followed them for over five years. They found no difference in revisions. They did have only one deep wound infection in the rheumatoid disease. Another study, this was with cemented mobile bearing ankles. I don't know how many people do cemented mobile bearing ankles, but this study at five years showed a rather high tibial migration rate in rheumatoid population and 29% Taylor subsidence. So you have to be careful in your rheumatoid patients and discuss with them expectations. If we look at diabetes, a study by Gross had 50 patients with diabetes compared to 50 patients without, very short follow-up, but 10% in the diabetic population had a secondary procedure, but 14% in the control group did. So they found no difference in failure rates. Another study looking at a large, very large group of total ankle replacements, complication rates in diabetics was almost 8% in non-diabetics, 4.7% in diabetics had higher rates of transfusion, home discharge, and overall complications. So I would say we should be wary in our diabetic populations. What about smokers? I'm just not operating on smokers with total ankles. And the main reason is I worry about their wound healing issues. And if they can't stop smoking, I think they're safer having a ankle fusion. So overall, I think that total ankles are going to eventually fail. So we have to be mindful who we put them in. Salvage is not always successful and often complicated. Most of the studies, even on outcome, now that we have, we're having great studies done by people like Alistair, but most of the studies we have out there have shorter term follow-up and a lot of fall of flaws. And like I said, about age, you could put in, put in one in somebody 50, but at 60, you're going to have to think about what you're going to do. And then at 70, you might be really challenged at what you're going to do. So my indications are patients generally who are greater than 55. I like to get them closer to 60, but if they have a lot of subtalar arthritis, I'll do them at a younger age. I try to keep their BMI to less than 35. But again, I've done them in older patients, careful with your rheumatoid patients, careful with your diabetic patients. Try to pick patients who have some decent range of motion to start with. Make sure the foot and tibia are well aligned and that any coronal deformity you have, you know how much that is. And I wouldn't recommend doing more than 20 degrees, especially if these are, if you're new to ankle replacements and you need to discuss these risk factors with the patients. Just a couple of cases. So this lady's 88 years old. She's active. She's independent. She did not want an ankle fusion. So I put a total ankle in her three years later. She's still active and independent and doing well living in Florida. This is 78 year old with 23 degrees of valgus tilt. Again, didn't want to, didn't want a fusion, had a well aligned foot. So we ended up putting an ankle replacement in him. He's done well and very happy. But if you look at his three years, you can see he's starting to tilt into a little bit of valgus. And maybe I can hear from Dr. Lee how we can prevent this, but he's still happy and now wants his other side done. This is a 72 year old. So her BMI is 40. She's got the various deformities. She's got a cavus foot and she has Pantaylor arthritis. And I just not, did not think this patient was going to do well with the Pantaylor fusion. We put an ankle in at a year. She's very happy. Then this final case, 49 year old, she's got a little bit of varus tilt. She's got a non-union of her fifth metatarsal. She again, refused an ankle fusion, was willing to accept complications of having ankle replacement at an early age. We put the ankle replacement in. I tried to use a little lower profile prosthetic, corrected her deformity, even her fifth metatarsal healed and she's happy. Thanks. All right, Sam, very scientific and we're over a paucity of information and I appreciate you going through that with us. You know, more and more I refer back to your group's paper on persistent valgus tilt after a triple arthrodesis and residual medial column instability. Do you take that on with valgus total ankles in the same way? Well, again, you have to, I think those are the cases where you really need to correct the foot. Those are the ones that you have to stage and really correct the foot. If the foot's corrected, I really think you can get, you can correct a lot of deformity at the ankle. One of the questions in the chat was, are you putting ankles in patients with cavus feet without the correction of the foot? What you're saying is the correction of the foot is almost as important as getting the ankle at neutral. So yes, in a cavus feet, you know, yeah, I think that we probably don't, at least I don't probably correct enough of the cavus feet. You know, what is too much? What is, you know, what is too much where you have to correct? What is, you know, I don't think we have great studies on that. I think some of the minimally invasive techniques we have now to help with doing things like calc slides, which is a great way to correct will be really helpful in doing these things as single stage procedures. Well, absolutely. And hopefully we'll get to the cases and talk about, but I'm really interested because Dr. Lee's group has really been pushing the envelope in research, telling us we can do more and more coronal stability. So Dr. Lee, why don't you put your slides up and, and then we can go from there. So share your screen. It's okay. Yeah, perfect. Go for it. Yeah, I think you can start. Okay. Good evening, ladies and gentlemen, and my colleagues, especially the moderator, Dr. Davis. I'm Gunda Lee from South Korea. My topic is about total ankle replacement in ankle with coronal deformity today. My has, I'm has no conflict with this course. One of the key factors for successful outcome of total ankle is minimization of residual deformity. Preoperative coronal deformity has been related to residual deformity after total ankle osteoporosis. According to Campbell Operative Orthopedics, the angular deformity more than 10 to 15 degrees is the contraindication for total ankle. However, advancement in design and the surgical technique allow this concern to be challenged. In general, various deformity less than 10 degree concomitant procedure is not required routinely. Sometimes, medial deltoid release is necessary. Let me show you the bilateral cases in neutral alignment. The easy case, at the 16-year follow-up, in front is well maintained without any major problems. Let's watch the video. The patient works comfortably and is very satisfied. It is the physiologic, I think, then the osteoporosis. For the various deformity over the 10 to 20 degree, more than one concomitant procedure are needed. In general, medial deltoid release is usually performed. Additionally, lateral ligament repair, ATL, the tibial corrective osteotomy, and the hind foot deformity correction are sometimes needed. If the intraoperative lateral opening is occurred, my surgical correction sequence is as follows with step 4. First, check whether the component is medial fitting. Second, is deep deltoid release. And if it does not work, try to do a little more telodrome upper medial bone cutting. Finally, perform the lateral ligament repair. As shown on the right, it is important to finish the operation after the medial lateral ligament balancing is completely correct. This is a case of 20 degree various deformity. On the preoperative varicose correction the telodrome was slightly corrected. This is very important in my step. Despite the precise cutting of the tibia and the telodrome, additional deltoid release and ATL were performed. The medial gap was still tightened. So at that time, I have performed medial myeloid distal sliding osteotomy. It looks like this. And it was able to get good coronal alignment. At the 8-year follow-up, the patient's satisfaction is very high with good alignment. The telodrome was good. Can you watch the gait video of the patient before and after surgery? What should we do when coronary deformity is over 20 degrees? If we cannot correct the deformity by bone cutting below the syndesmosis, we could consider SMO. Let me introduce a severe varus case of 33 degrees. In Belger's correction view, the teladon was corrected, but varus deformity of the distal tibia platform was very severe. So a distal tibia medial opening HOS was performed to obtain good tibiotelar alignment. Total recolossal thrust was done after achieving good tibiotelar alignment. It was very well maintained at 3 years postoperatively. This is a similar case with 36 very severe varus deformity. You can see the medial articular surface of the distal tibia was dented deeply, and it was not fully corrected in the Belger's correction. I performed SMO concurrently with total recolossal thrusting. At the 10-year follow-up, the patient satisfaction is very high with good alignment. As you can see in the video, patient works very comfortably. Which one do you think had osteoporosis? Let me show you Belger's case with 20-degree deformity and Hindford-Belger's. For this case, deltoid repair was performed for the deltoid insufficiency, but Hindford-Belger's was still remained after surgery. I wrote about that. However, we observed this follow. In the post-operative four years, the teller component was Belger's deformed and multiple osteolysis was developed. Interoperatively, we found the broken polyethylene. This is the first time I performed calcaneal medial sliding osteotomy, deltoid repair, and cyst, cleftage, and allopone graft and polyethylene exchange. At the revision surgery six years follow, he is living a satisfied life without any problems. Let's look at the case of more severe Belger's case. It is a 40-degree Belger's. Even though severe Belger's deformity, it was easily corrected in the various correction pre-operatively. As you can see, fibula and calcaneal form articulation due to severe Belger's deformity. I obtained medial stability using medial malleolus superior sliding osteotomy. At the six-year follow, the outcome was good and the alignment is well maintained. From now on, I will show you our three studies. First is the comparison of the outcome of total across osteoarthritis with moderate and severe Belger's alignment and the neutral alignment. We divide into three groups. The moderate group was set to 5 to 15 degrees, and the severe group was set to over 15 degrees. On the result, the L-PAS, PAS, R-M complication rate did not differ among three groups. Severe Belger's group showed less corrected alignment than neutral group. Belger's group had a more additional procedure than neutral group. Our study results were cited in the Canberra Operative Orthopedics. We reported a satisfactory clinical and radiotherapy outcome in patients with moderate and severe Belger's deformity, similar to those in patients with neutral alignment, and post-operative neutral alignment was obtained. The next study is comparison of intermediate to long-term outcome of total ankylosing blast in ankle with preoperative Belger's and neutral alignment. The Belger's group had a more concomitant procedure than neutral group, which is similar to the previous results. The L-PAS, L-PAS, and AOS-SF36 species did not differ among three groups. Our results demonstrate that outcomes similar to those in ankle with neutral alignment were obtained in ankle with Belger's alignment, but alignment of up to 20 degrees when neutral alignment was achieved with total ankle. How about the coronal deformity greater than the 20 degrees like this? This study is about the outcome of total ankylosing blast in ankle with over 20 degrees over the coronal plane deformity. We compared 41 severe deformities of 20 to 35 degrees and 107 moderate deformities of 5 to 15 degrees. There was no difference of AOS-SF36 species past ROM complication rate. So, we conclude that the TAA may be considered in ankle with a severe coronal deformity of 20 to 35 degrees. I would like to introduce rheumatoid arthritis patients with hind foot and mid foot fuselage state with 25 degrees of Belger's ankle. So, ankle motion should be same. Therefore, this patient is, I think, an ideal indication of total ankle arthroplasty. At a 14-year follow, he's very satisfied with well-maintained total ankle. Let's watch the video. I say again, I question you, which one do you think had arthroplasty? I like this. This is very physiological. This is the last case. He had a trauma in childhood, so his ankle had a severe varus deformity and fixed ankle motion. It was 36 varus deformity and 3 cm of shortening of the right tibia. So, I performed supramalleolar osteotomy and knee-jerk correction. At the first of 10 months, we achieved good alignment. After that, right lower limb and ankle were well aligned. He really wanted to restore ankle arm at the time. So, I did total ankle arthroplasty. At the 10-year follow, the patient's satisfaction is very high with good alignment. On the gait video, the patient's gait is slightly unnatural due to limited right ankle doge flexion motion. But he's living a very satisfactory life. This is my take-home message. Total ankle in ankle with preoperative moderate and severe deformity and varus and varus deformity showed similar satisfactory clinical radical outcome and neutral aligned ankle were achieved postoperatively. Our results suggest that total ankle arthroplasty would be a viable treatment option in ankle with severe deformity. And indication for total ankle can be expanded to ankle with deformity greater than 20 degrees in some cases. This is our hospital. Richard, thank you very much. Dr. Lee, thank you so much. That was impressive. I'm interested because I do big deformities, but I rarely will do associated supramolar osteotomy. And I'm wondering if there's a difference between my reliance on fixed bearing versus mobile bearing. When I did mobile bearing, I was very nervous at doing anything that the tibia wasn't perfectly aligned. Do you think that that may be a reason that you're doing more tibial osteotomies or I don't know, Alistair, I know you've got a fair amount of experience with mobile as does Sam. Do you think that that could be it or am I just missing something here? You're absolutely right. The newer designs make it much easier to correct and and things that have worked in correcting deformity. I mean, thinking all the way back to the beginning when we're using the agility, it's very easy for that to tip. And so you had to be absolutely on on your correction. So you're much more likely to do a supramolar osteotomy to get an agility. And then we saw a lot of Hintagras and the Hintagras do require pretty good balancing. I'm using a lateral approach ankle and I find that the, you know, the polyethylene and these fixed bearings with the with the geometry that they have to sort of centralize a bit is really good. And so things that I used to osteotomize, I don't osteotomize and the fixed bear, the the the lateral approach goes in on a frame. And so, you know, so long as the ankles pointing at the knee, it doesn't really matter quite so much what's going on in between. So you get as long as you get the ligaments balanced. So that means, you know, often we use a bimalleolar osteotomy, which was was taught to me by Baird Hintmann way back when. So, you know, there's lots of tricks. And, you know, the time I think to do a supramalleolar osteotomy is if you think you can get some mileage out of it. So if you've got a patient where, you know, their ankle looks like it may be able to get by for a few years, then doing supramalleolar osteotomy first might delay the ankle joint replacement. But that's one of my, you know, Andy Valkovich, my colleague, she does a lot of osteotomies, as does Baird Hintmann. And I don't think we've really worked out, you know, exactly how osteotomies fit in our whole algorithm. And we talked about technique, and, you know, osteotomies are very technique dependent. There was a nice paper out on that recently as well, comparing osteotomies and fusions. So I think that there's a lot to learn still on what, you know, what you can salvage and when you can osteotomize and, you know, still get some mileage off the native ankle. Dr. Lee, how do you determine how much correction to get with your osteotomy before you come in on the same stage with the primary total ankle? Yeah, in general, less than the 20 degree, as I talked to you, the patient's right, and the medial deltoid release and lateral ligament repair is sometimes possible. However, in general, I think over the 20 degree of the distal platform, the slope is over the 20 degree, probably necessary for the distal tibia opening at the osteotomy first. And then the aligned tibiotelar joint perpendicular to the mechanical axis of the tibia, and then put the total ankle is the solid options. So greater than 20, you're doing a stage procedure to correct the tibial deformity and then coming back and doing the replacement. Under 20, you'll do the osteotomy at the same time. Yeah. And in the beginner, for the less than the 20, 30, the total ankle osteoporosity, just I recommend the stage. However, some experienced surgeon, the same incision, so that the experienced surgeon can put the ankle and the osteotomy simultaneously. Yeah. As I tell my trainees all the time, there's no sadness in staging something. Any comments, Sam? I know you do a bunch of osteotomies also. Yeah. My feeling is, I really worry about soft tissues. I always tell my total ankle patients, what I worry about is catastrophic failure. So if that will get them to do something staged, and understand why we have to do it. So I would stage almost all those. Okay. All right. We're going to just do a few cases. We have about 10 minutes. The first case, I think, brings into this whole conversation of how much do we need to do with an unstable foot. I do have some conflicts in particular. I have three total ankle design out that you'll be seeing. So the first is a 52-year-old female. She's 52 in 2015. So that's important just because we're going to follow her for a while. Bilateral recurrent ankle instability. So she had multiple ankle sprains. And my experience with ankle instability, that's a whole other conversation, is some of them collapse into valgus, and some of them collapse into varus. And so now she's got severe left ankle arthritis. And you can see here, yeah, she's got a little navicular cuneiform collapse on both sides. And I'm sorry, she was right side first, okay? And she's got some medial column instability. So Sam, is this one that if you're gonna do an ankle replacement, she's kind of squirting out the back and has just a little bit of valgus collapse. Is this one that you're gonna do something about that medial column instability or are you gonna leave it alone? I gotta tell you, I'm probably leaving that one alone. I'd like to see an AP of the foot too, but that doesn't lead me to think I wanna do something with that degree of instability. Okay, so you can tell that that's what I did also. I left it alone. And so I was a little concerned about the lateral gutter, but there was no collapse. So I was saying, okay, I'm probably good. And she went away for a while and came back at three years for her yearly follow-up. She missed the first two. And you can see that she's beginning to plantar flex to her first ray. And I'm sorry, I do not have a foot film in here, but she does not have a bunch of tail and avicular and coverage that you would kind of expect with this kind of deformity. In addition, you can see that she's now loading the anterior portion of the tibial plate. And there may be a little bit of tibial subsidence, but again, she's symptom-free, no medial pain. Is there something to do here or do you just watch this because she's symptom-free? Very difficult to do an operation on an asymptomatic patient. You can always make them worse, hard to make them better. That is true, all right. So a progressive flat foot under a ankle that seems to be looking all right, but a little bit of collapse. And so you think leave her alone at this point. Okay, so she comes back at four and a half years from the first side. So it's now 2019. She's still symptom-free on the right. I'm a little concerned because it looks like she's collapsed a little bit in the valgus. And now she's got severe pain on the left and she's definitely collapsed in the valgus on that side. So, Alistair, do we do anything different here? Dr. Lee, is this one that you would consider an osteotomy or it's much less than 20 degrees? Why don't you help us with this? So is this one that you think you could do soft tissue balancing? I think still the ankle joint is a little bit of a tenor tilt valgus. However, the main symptom is produced in the high-depth valgus deformity. So I would like to post a high-depth alignment correction. Probably that making an ankle realignment. So I suggest a high-depth osteotomy. You think you would do a medial displacement calcaneal osteotomy and leave the medial column alone? Yeah. Do you do all that at the same time as your ankle replacement? No, no. No, don't touch the ankle. Oh, don't touch the ankle. Don't touch the ankle. Okay. But that's where she hurts. But you're going to say, I'm going to fix your flat foot even though your flat foot doesn't hurt. I think the medication and the heroin-like injection is to subside the ankle pain. And then, anyway, I think firstly, the correction of the high-depth valgus, probably valgated the ankle will be corrected neutrally. However, and then you can judge, you can consider the next plan. It's the total ankle or any kind of options. Okay. Now you see here, Sam, I refer, keep referring back to your paper with medial. Yeah. But, you know, I actually think her left looks worse than her right. I agree. So if you're going to do a replacement on this, do you fix the flat foot or not? I think I would. Would you do it at the same time? Would anybody leave the flat foot or do what Dr. Lee suggested, which is to fix the flat foot only and hope that that helps her knee replacement, helps her ankle arthritis, despite this kind of collapse with also this? Yeah. I think the answer lies in the medial column and I would do an NC fusion personally and possibly a TNT fusion. For fellows and trainees, I'd encourage them to do a two-stage and make sure they do it well because the primary thing is you got to get that foot straight. And then if that means two straight stage, that's great. If you can do a single stage, you can help the patient, but it's an operation you got to keep moving if you're going to do it single stage. Agree. All right. So this is one I did. I was much more aggressive with the flat foot. I chose to cheat a little bit and use a cotton rather than NC fusion. I think it's easier and reasonably reproducible. She didn't have a bunion. She did have the hallux rigidus. And so this I did two years ago and I did the MDCO as Dr. Lee suggested, as well as a cotton osteotomy. And you can see that on this side, I used a little bigger poly despite using the same implant, as well as the same type of preoperative planning. The lateral gutters, there's no lateral impingement. And I don't think I can talk her into fixing her flat foot on the other side as she's asymptomatic now five years out. But every time she comes in, I warn her about this. And I think this is my learning curve that you're seeing here, that now I would never leave that instability that I left on her first surgery. And so this is kind of where I am in her now. And this was two years ago. And this is her at two years. The interesting thing is I've lost some of my correction without doing the NC fusion. So Alistair, maybe that was really the most appropriate operation. I think on the other side too, still a lot you can do without reoperating on her. Like I'd be getting her an ASO brace, or sorry, like a Ritchie brace, a double upright and an orthotic. And I'd be following her annually and keeping a close eye on it. And you may well be able to buy time with bracing and stuff, just so external correction rather than internal correction. Yeah, every time I try to put a brace that is fairly restrictive, like a Ritchie brace on a patient, they go, well, then why didn't you just fix my ankle right when you fixed it? An orthotic certainly is something that she has. All right, I think we've got time for one more just in the chat. Yeah, Julie, did you put the, they're asking on the chat for the CME info. So you've got that, thank you. Okay. So this is just a fairly straightforward. This would be probably a COFAS4 because of subtalar arthritis, but really not much deformity. Pretty straightforward. As far as at 70 years old, is there anyone on the panel that would even consider a fusion in this patient? Yes, if they had comorbidities. And in general, my fusion is a bimodal, like the very young and the very old. If I've got sort of an 80 year old that needs to maintain mobility, I'll do an ankle fusion arthroscopic and minimize wound complications. Do you get nervous about the subtalar arthritis? I didn't put the CAT scan in, but he's definitely got subtalar arthritis with an ankle fusion. Even at 70, I just, my ankle fusion patients who have subtalar arthritis, they come in and say, doc, I have buyer's remorse at six months. And I'm saying, well, you're fused. Why are you worried? And they hurt. Yeah. I think it's a hard one. I, you know, like, I mean, the Duke papers sort of changed my attitude a bit on this, the potential risk of AVN. I've done probably, I've done six to 700 total ankles and I've probably done about 150 combined ankles and triples or ankles and subtalers. I haven't seen a terribly high rate of AVN, but I'm more likely nowadays to do an isolated total ankle and tell a patient if it hurts in the subtalar joint, I'll go back and do an arthroscopic subtalar fusion. And that sort of mitigates the wound complications. And it also mitigates the risk of AVN. And if they really want one stage, I'll do a combined total ankle and subtalar fusion. And a lot of- Dr. Lee, will you do subtalar fusions at the same time as a total ankle? Same setting? Yeah, I'm not sure. I needed the more information of a patient. Anyway, in my experience in my clinic, I have been checked the bone spec to evaluate whether which side is the main, the pain source, the ankle is major. However, secondary is subtalar joint. So anyway, in my experience is a total ankle first and then we follow. However, the bone spec is and the positive imaging and then the redocaine injection, something like that. And the one patients is the severe pain and subtalar sinus pain. And I would like to do simultaneously subtalar fusion and total ankle. I mean, in general, total ankle alone is leaving the subtalar joint. Yeah, that's kind of been our philosophy is leave the subtalar and see what happens later. Sam, what's your opinion on that? I would just do his ankle. I would do, as long as his soft tissue envelope was good, I would just do his ankle replacement. I did a lot of combined procedures early and I don't do them anymore. And I can't tell you that I'm going back and doing a lot of subtalar fusions. I agree. We're doing a study now. We're looking up our patients in our registry. Anything special with this posterior subluxation? Sam, do you tell the patient you're gonna have to do something? Is posterior subluxation different than anterior subluxation? We certainly see these in this post-traumatic with that posterior lateral, posterior mal fracture. Yeah, I mean, I have not had too much of a problem with the patients who are posteriorly subluxed. And other than maybe doing a TAL on them, I haven't done much else. That's been my experience also. So this is one, this is first post-op and this is 12 months. And Andy Delcovich published on that and she showed that it was a good idea to publish on that. And she showed that if you're anteriorly posteriorly subluxed, your risk of failure is higher. So I do think you need to sort of centralize the joint as best you can. Don't disagree with that. And there's some balancing involved in that. All right, we are out of time. And those of us who have been doing this for a while, Alistair and I were texting back and forth and the amount of information that was given to you, we couldn't have had this seminar even eight years ago. So I really appreciate the faculty coming with their A-game because the quality of this information is phenomenal. And I love when I spend an hour learning from some of the best. So thank you all so much.

total ankle replacement surgery

factors to consider

patients with deformities

ankle replacements

ankle fusions

complications

studies

moderate to severe deformities

outcomes

decision-making process