Dr. Murray Penner discusses the evolution of his TAR practice over the last 20 years, specifically his views on TAR vs. fusion, his experience with a variety of implant systems, his algorithm for prosthesis selection, and many other related topics.
Good evening, everyone. Uh, my name is Nathan. More with right medicals, total ankle marketing team. Welcome to the next installment. What we're now calling the fast program, which stands for the right the Frank right ankle specialist training program. So, as a marketing guy, I felt like it was time to come up with the name that was a little catch here and fast program seems to roll off the tongue a little bit easier than advanced our specialist program. So I felt like we're going the right direction there. So thank you again for your willingness to be part of our inaugural group of attendees as well as your flexibility as we continue to move through this covert situation and get a little more experience with these Webinars. But with that said, you know, our hope is certainly at some point next year, the environment will be such that were able to arrange some of our originally planned activities, like whether to b o r visits or dinners, even possibly a single day didactic course, or even a combination. But in the near term, you know, we'll continue to plow ahead on hopefully we'll get some good news is we go into next year. So tonight's focused. It's gonna be part one of two that we're gonna be focusing on Complex primaries will be the follow up to this will be part to Naturally, it will be in October and will be have another faculty member providing some additional perspectives on things like Colonel deformity addressing the foot infection and many other topics. So and then in December, our hope is that we can, you know, make scheduling work for everyone early early December. Ideally, and we would do a, you know, a talk on revisions and and even get into multistage procedures as well as talk about some things like, you know, the business side, whether it be, you know, expanding guitar practice, driving patient awareness and those types of things. So obviously a lot of opportunity for Q and A. Aziz. Well, so real quick. Just a couple of zoom housekeeping notes. Number one. We invite all of our surgeon attendees who have now been who have now been promoted to Panelists. It looks like, uh, that you are welcome to interact. We go along, just be sure to turn your camera on, and, uh, and also a mute your mic. If you do have a question, we do have a Q and A box as well that you can use. But certainly, you know, there's a small enough group here where if you guys wanna just chime in, certainly feel free to do that. We want this to be a Z Interactive as possible and and also just know that this is being recorded. So this is something we may use our virtual learning center down the road. So before I pass it over to Dr Davis is gonna introduce our speaker and the topic for tonight. It's been a little while since we got together, so I figured I would just kind of run through. Our different attendees here just kind of introduced everybody. So I'm just gonna go in alphabetical order. So looks like tonight we've got Dr Jeremy Adams out of Oxford, Mississippi. Dr. Adam Bitterman out of Huntington, Huntington, New York. Dr Ryan Callahan from 20 Falls, Idaho. Dr. James Lackman from Quaker Down, Quakertown, Pennsylvania. Dr. Loro Credit Loro from Springfield, Massachusetts. Dr. Michael Leave, from Spartanburg, South Carolina. Dr Patrick Maloney from Baltimore, Maryland. Dr. Aaron, Mates from Trinity Florida and Dr Jason Patterson from Phoenix, Arizona, on Dr Greg Scallon from Richland Washington, and Dr Brian Studzinski from Columbus, Ohio. So thanks again to all of you for joining us this evening. And with that, I'll pass it to Dr Davis. All right, Nate, thank you so much. It's it's always exciting for me. Thio be on a program with my good friend Murray Penner. Um and I'm gonna change my background. I'm actually in Sun Valley, Idaho. Um, which is why it looks like I'm so relaxed. Um, but our goal with this program is to introduce the inaugural group into a zoo, many talented and smart Arthur plastic surgeons as we can. And when that list comes up at the top of the list is are always Murray Murray has been been super influential and the design process with right medical as well as has been the leader in the Canadian Orthopedic Foot and Ankle society and all of the similar work that they have done in defining the demographics of ankle arthritis. So So I am. I am so glad to carry Murray's clubs here, and, uh, and I'll be here. Thio both listen and uh, and to maybe facilitates. Um conversation. Murray, you will thoroughly enjoy this group. These air these air super smart focus guys who we're right up your alley. So, Murray perfect. Well, thank you, Hodges. That's really kind of you gonna really appreciate the opportunity Teoh to be a part of this. Uh, this this group, this is This is exactly the way that I love Thio be involved with with teaching and learning. And, you know, in small groups, I think in scenarios where you can kind of talk to people back and forth, share some dialogue, hopefully kind of get a sense of whether the person you're listening to is actually believable or not and ideally, be able to interact in a way and and challenge and then learn altogether. Janice, Nate. Thanks for organizing this. It's it's a real treat. And I'm coming to you guys from Vancouver here across a bit of a border. But we all are in a soup here together, so it za great to be able to interact this way. You know, it's maybe not quite as good as in person. The topic I was sort of asked Thio to speak a bit about and today is is kind of a large topic. It was meant to be around primary ankle replacement, but kind of from the perspective of maybe sharing how is or you know, what? What's my perspective on ankle replacement? How does it fit into my practice? Now, what do I do? How do I look at it? And then how did I get here? And so I've been doing this for about 20 years, and it struck me that trying to summarize all of that. And, you know, Thio fit into 20 or 30 minutes of talking and giving some time for discussion that that was gonna be challenging. So you're certainly not going to get every last little, uh, truism that I think exists an ankle replacement. But I'll try to share with you some of the things that I think are at least we're thinking about and how I think about them. You can challenge me on any of these things, of course, And then we'll have ah, handful of cases at the end that I hope will be open and interactive with lots of engagement. Eso Here we go. I've been at this for 20 years. And, uh, it's been an interesting 20 to say the least. I'm going to share my screen here. Now, if I can get button going and do let me know if you're not seeing what you're supposed to see you. So I think maybe just give me a thumbs up if you can see my slides there and we're just gonna get going. So 20 years of ankle replacement, you know, how did I get to this point? Well, thes air, my abused the outline today is pretty straightforward. I'm gonna talk a bit about how I currently use ankle replacement in my practice. And we're gonna talk a little bit about how I got here and friend of you paying attention to the pictures on the right. You haven't sort of betraying my age at this point already. So it's 2028 where we are now. And the question is, how do I approach some of these things? And I could have put up a very long list of variables that I think are important to think about an ankle replacement. But I picked these handful because I think these represent some of the most important ones released. They're the ones that I get asked about a lot, kind of how I think about it. And so we'll touch on these and then move on. So getting right to it, The first of these is the one that kind of comes up almost more than anything else is age, age and anchor replacement. How how do I think about this? And how do I think I just should think about this? What do I use is my guide. When I'm thinking about age and ankle replacement, I think about this work salvage ability, which is a funny word. And why would that matter? Well, when you think about about it, here's a case example. Here's a patient. This is a real case of mine. A 49 year old guy, he's had an ankle fusion on a sub Taylor fusion. They were done sequentially, but he's now left with this effective TTC fusion, and he's now got considerable Taylor Victor joint pain. It gets better with blocks, and he's finally fed up with this, and ultimately, how can you salvage this situation? So he's got a failed ankle fusion. Well, this is a relatively easy salvage to a total ankle that takedown total ankle. Here he is four years out, doing very well, very happy with this outcome. Contrast that to this another patient similar age who's had an ankle replacement done by me in a room with severe rheumatoid scenario, and it's clearly gone to hell. And how are you going to sell with that? And for something like this was really almost no salvage it all. She's got an equally bad looking ankle without an ankle replacement on the other side, so we can't just do an amputation and things she's left with. This is your only real salvage. And so where, where we are with that? Well, the difference here is bone stock. And so when you think about failed ankle fusions, these generally people with some bone stock, and that means you've got some options for salvage. So I think of it this way, and patients who are at an increased lifetime risk for failure you that over the course of the hopefully a good long life, they will experience a failure of whatever choice of reconstruction I make. I tend to prefer ankle fusion. So who are these patients? Well, think about this, you know, hint. Sherman's group showed us many years ago now that the patients less than age 70 they were significantly increased risk for a need of revision. When we look at survivorship of implants down 15 years, maybe 50% or a little bit better, depending on which device we're looking at. What this tells us is that if you do ankle replacements and patients below the age of 55 or 60 they're gonna be a very high risk of meeting at least one revision. But if you drift much below that, you're looking at patients who will likely need two or three revisions in their lifetime, and that means they need to be salvageable. And so what can we conclude? Well, in the young patient, that salvage ability is gonna be really critical, and they're gonna be a high lifetime risk of failure. They need that salvage option and salvage options or greater and ankle fusion because you've left him with bones talk. And so I look at ankle fusion is being a preferred out your preferred reconstructive option for the very young patients, and I don't have a hard cut off. Like I said, I think about it from that salvage ability. Perspective. It's kind of a very thick, blurry line around the age of 50 and it depends on so many other factors. But that's how the perspective I'd encourage you to take and looking at it don't have a hard number of hard cut off. Look at it from the perspective of how are you going to salvage? That's when it all goes sideways. And here's a bit of example of just how I apply that this is a patient with hemochromatosis, so bilateral ankle arthritis. You see here it's 48 years old, and so in that scenario, what did I do? I didn't arthroscopic ankle fusion. He was very happy with that. But six years on, he already was having considerable pain in his right ankle at the time. He did that Fusion, his right ankle has got worse and worse and worse. And now, six years later, he was purposely holding off because he didn't really want to ankle fusions, and he was now age 54. Though he was very happy with his left ankle fusion, he really didn't want that. So we went ahead and get an accurate placement now that he's 54 years old on his right hand side. And so this is what he's like now. He's got a fusion on one side. He's happy with the replacement on the other side, that is happy with. But I'm playing the odds that we're gonna get enough longevity now out of this right hand total ANC replacement that if we need to salvage that down the road, we can his ankle fusion. That's gonna be a matter of pulling a couple of screws out and putting an act replacement in there when the time comes to do that. So that's kind of how I look at age. One of the other things that we get talked about a lot is diabetes and other co morbidity ease. How do I think about that? Well, that should be an easy one, but diabetes isn't really a binary problem. There's many different forms and severity of it. When I look at this, these air kind of my rules of thumb a patient. If they're going to consider an ankle replacement, they definitely need to have good sugar controlled hemoglobin. A one C is below seven. Really, they need to have normal vascular it and not just okay. They need to have strong pulses, no calcifications in their vessels. You need to have normal skin. And I think that's almost the most important one. No ulcers, of course. But you know what? This bastard changes and really normal colors. What I'm really looking for clearly no neuropathy. I had I don't really adventure into that at all. I think vibration senses the test that I use in my practice, and it needs to be normal. They also need to be highly compliant patients because they're gonna have a storm. Your course, no matter what. And if you've got somebody that's already pushing your buttons a little bit before you get going, it's not going to turn out well. And then they need to be old. Enoughto likely never need a revision in my mind because that they're only going to get medically worse on that revision is gonna be a problem when they get to be quite elderly and diabetic. And so, if you're reading between the lines here, maybe it's quite obvious that this is quite a rare, idealistic patient. They do exist, but they're not very common. So Here's an example of what I mean by that. That's a 78 year old guy with ankle pain and instability. He was a former rugby player, but he's got diabetes steam, global. Anyone sees typically running about 6.8. That's okay. Maybe he's got some spinal stenosis, though. In a mild dropped foot on that side, he's still get around to it certainly stops his foot a little bit. He's also got a fairly flexible flatfoot below this analogous ankle arthritis, but most notably has got decreased vibration sense. He's not. He doesn't feel like he's really non, but he certainly has diminished vibration sense. And he doesn't have a D P Pulse and he's a pretty big guy. And even though that sounds like that's not that bad, what did he get? My practice? I just did this a week and a half ago. Hey, gotta valor nail. And there was just no way in the world that in a 78 year old guy that with these combination of problems that I was ready to take a chance and doing a total ankle here. And so that's sort of an illustration of the common type of diabetic patients, see. But there are those exceptions, and I will consider that replacement for them. But it's really rare in my practice. How about wait? Waits? Another question. I get asked a lot about my own, perhaps, but more about patience. And that is, Is there a cut off? Is there a limit on this? Well, I learned a lot about that quite a while back. This is a patient from long ago in my practice. He's a 57 year old guy at the time. Back three years before I did his total ankle. Hey, had a activity, a fracture that I fixed. It went on to non union, took the nail on revising with plating, and that ultimately, he'll they had this ankle arthritis. So in 2000 and three had a star ankle done in his age 60. Because you know this from the top. He was 6 ft 3 £300 when this started. By the time that I got that ankle replacement, he had gained even more weight and by the time unfortunately passed away about three years ago, now he was up to about £375. But the One thing he always told me was his ankle was not his problem. Hey was actually really happy with it. And when you look at these X rays from 14 years out, they look fantastic for a star ankle at that point in time. And what that told me was that really wait itself as an isolated issue isn't really is something to get too worried about. That goes along with the literature that's out there. I think you need to be very cautious with heavy patients. But heavy patients can have excellent outcomes and interviews. Group again has shown that that's quite a while back, but I think that's still a very true statement. I think it's really about the other factors that may go along with their weight that you really want to think more about another factor. I get asked a lot about his co fast type, and for those of you who don't have it sort of in the front of your mind, the co fast type is really divided into two types. Complex and non complex ankles and non complex being either no deformity or simple intra articular deformities in the complex types of more severe foot tibial deformities or those with hind foot arthritis and the type fours. And without getting into too much of the literature around all of this and all the studies we've done within co fast to look at this. What we can say that is that co fast type one patients with minimal deformity. The difference between outcome between ankle replacement in arthroscopic fusion. This was just published by Andy Belkevich in our group, J. B. G s not too long ago eyes really the same, and the differences really are noticeable, most noticeable in co fast types three and four. And so those patients that I steered directly towards an ankle replacement that might sound funny. They're more complicated, difficult ones, but that's who really stands to benefit the most. That doesn't mean a co fast one patient shouldn't have a total angle. It just means that pushing them hard in that direction isn't really something that I personally do. I let them choose in those regards, but I think it's still important to then consider their age. They're really importantly, their activity aspirations, their co morbidity is and medical surgical risk. But then they're deformity, stability, neurologic status and vascular it and we're gonna come. Or to that. Here's just one example that a patient of mine and this is from two weeks ago now I think, and he's 63 years old. Post traumatic arthritis, as you can see here, clearly has some significant tail in victory, arthritis and some sub taylor arthritis. But these patients now I happily talked about and replacement by the way, digging that hardware there was an absolute nightmare, but nevertheless we did. We put some prophylactic fixation into his medium alley all this and put in an ankle replacement of Difficult and you'll notice I didn't do anything to his hind foot. We got his ankle moving well enough that I really do believe. And it's this is born out in my practice, and I think Hodges would agree that hind foot arthritis symptoms really seem to be diminished significantly. If you can get the ankle working. Well, that doesn't mean they always go away completely. And have I ever had to go back? Thio do a subject of fusion? Yeah, once exactly once. Eso it's pretty uncommon, so I tend to even these co fast type force. I don't inherently jump on their sub Taylor Taylor Victor joint. Unless it's really, really critical or clear that you're gonna need that. Another question I get asked a lot about is implant type. How do I choose between infinity and in bone? It's a big topic in and of itself, but I look at this whenever a primary and replacement is an indicated operation and and this is a clear and deformity is relatively minimum can be predictably fully corrected in your hands or in mine then and there. Bone quality is within normal range. That's when they're going to get a infinity. When don't I use an infinity? Well, there's a bunch of scenarios. Bone quality is a really big one for me. So if they have rheumatoid arthritis like this was just ghostly bone that's going to get on in bone a stemmed implant to distribute those loans or if they have poor bone quality because of a previous pylon fracture with potentially at the end of the distal tibia. That's also going to get an in bone like you see here, and age and gender and avian play into that a little bit as well. Also, if they have very significant deformity. So embarrassed, like you see here, If it's severe like you see here, I think there is definitely an increased risk of some degree of recurrence of the form. You are at the very least of edge loading, and I think a more robust implant to interface is important there. I'm gonna use in an in bone and a stemmed implant as well. And for me, just about any valid us. So anybody was kind of valid us that you can really see or especially those who are dealt with insufficient. Those were all going to get an in born again. The very same reason. The risk of recurrence in the risk of veg loading. I think that's much harder to reliably fixed in a valid this type of situation. But for all others, they're going to get an infinity like you see here, then deformities another big one, and we're gonna talk about these things much more detail when you get to the cases. So I don't have a lot right here to go through but a little bit about Barrys. Well, I think Paris is definitely much easier than Valerie's to treat, and I really don't have an upper limit on the amount of deformity that I'm willing to take on. Just about anything is correctable if you take your time. Most of these air amenable toe one stage correction as well. But I think there are scenarios, particularly around the severe cable Vera's feet, that accompanies some of these various angles that to stage is really important on and on top of that. Over the years I've relearned, we're gonna come to this in the cases, be aware of the deformity ankle. So here's a big, long list. Don't even bother looking at this. But this is kind of how I have in my mind sort of work the process of going through the various ankle, and we're gonna touch on this. When you get to the case, what about validates what I find value? It's much more challenging than embarrassed. I think there are many more factors to consider. Valdas is sort of a soft tissue tensile failure problem, whereas various is really just a bone stacking problem that's much easier to figure out. Rule out, I think in my practice I rule an ankle replacement of the deltoid ligaments, insufficient then I put in there Unless And that is unless you or I can confidently reconstruct in a robust way the deltoid ligament. Because that 10 sile load is now. I'm gonna go onto that reconstruction and you have to be very confident that. But if you could do that, then I think they're Valukas realignment. Agosto lacks a very reasonable thing to do. But if that's not part of your practice, then I would suggest that deltoid sufficiency should rule out ankle replacement. I'm not gonna go through this in great detail, but I wanted This is just to tell you that I like to sort of think about the analogous in particular right from, you know, from hips to feed. Not that you should do that for all of them, but really more so even for the ankle. Actually, for the analogous ankle, I'm just kind of give you an example of what I mean. This is a mild August case, 62 year old female carpenter. She injured her ankle. It worked 25 years prior like we had this high ankle sprain and went on to develop the August ankle Arthritis. Uh huh. This is kind of my process. So look at the overall patient for her. She had no limiting factors, so I could do whatever I want. She has a leg that has no deformity, does have a tight gas rocks that's going to get a gas truck lengthening. When I look at her ankle level, she's got good quality bones, so I'm not forced to think about a stemmed implant there. Christendom's most was slightly wide and perhaps quite, but not necessarily stable. If you look at these extras, you'll see what I'm getting at there. It's not gross, but it's a little wide. So I'm thinking to myself, Be prepared to fuse is India's most if it turns out to be unstable at the time of surgery from a Leola, I looked normal, so I don't really have to think about osteo Tommy's. There's no real wearing and that sort of thing. She doesn't have gross ligament laxity, so I don't expect I'm gonna have to a lot of ligament to stay with stabilization. And when I look at the type in the severity of the value says it's lateral wear pattern, that's mild unit or deltoid must be intact, so I don't have to planet the ultimate reconstruction. And since this is post traumatic, she doesn't have a lot of foot before me. So I don't even think about a foot reconstruction. So I walked myself self through all of those steps and sort of think about the impact of each one and then go ahead and her particular case, but very straightforward total ankle, which where it has worked out really well for her in the long run. So that's just how I think with that. And then, lastly, what about tibial deformity we'll have to go to for me is mild. I like to think I can accommodate that within the cuts of the ankle replacement, but usually if if you're planning, you can usually only do this if you're planning to use a non stemmed implant because you change the U develop a deviation between the an atomic access the tibia, which the stem has to follow, and mechanical axis, which is what you ideally want to follow. So if the deformity is moderate or severe in the tibia, or if you're planning to use, extend implant and you must correct the deformity. Also, if the patients very young and you want to maximize longevity and optimize mechanics, I think it's really important as well. But this just illustrates that latter point you can see this. Patients got a valid ghost story of various tibial plateau faan with various distal tibial bow. And if I wanna put a stent implant in here, for example, you can see that if I put it along, the mechanical access is gonna sit in halfway through the fibula far too far laterally. But if I want to follow the distal atomic access, it's gonna poke out the lateral side of the tibia. So none of this is gonna work self evident. That's gonna need correction. So we throw in an opening wedge osteo autumn on the media side of the tibia, straighten it out, and we could put it in most straight up it like it belongs there, and it works out very, very well. So another just example, going a slightly different direction. That's a 67 year old guy who's had a previous peel on fracture with this anterior sort of impassioned pattern. So commonly see with a little bit of various and you can see on the far right there that if I'm going to try to put in in bone with the stem into this and I want to because his bone call it is pretty poor. It's gonna poke up the back of the TV, and that's not a great idea. So we do a two stage procedure here to do it opening wedge, osteo bi again, this time from the front realignment tibia. And ultimately, Now we get a chip shot in bone operation, and you can see just how much more corrected his anatomy now is. This foot sits below is tedious tales, of course, ascended right below the tibial shaft where it should be on those lateral views. So this is a scenario where again, typically forming in my hands generally needs to be corrected. So I'm gonna just pause there for a second because we're gonna jump to kind of How did I get to this point? I'm just sort of ran through that relatively quickly, and there may I would have expected either be a lot of snoring or a lot of questions. But, um, if there's any questions or anything or if Hodges, if you had anything you want to jump in this might be an opportunity to just change gears a little bit, Murray. Yeah. I mean, the evolution is is really interesting. And I look forward to that. Um, the the case that you showed you were concerned about the sentence, Moses with the valdas most likely caused by global ankle and stability. You chose to do nothing to descendants. Moses interrupt what makes you do something versus not because we all know that Ascend, demonic fusion, those of us who did any abilities, which I know you did. The cinematic fusion is not an easy inter operative decision to make. No. So in that particular case, and I don't do this routinely, but if I have a suspicion around Cindy's monarch issues, I will go all the way laterally there, get my Howarth in there and look and see what sort of level of instability eyes there. And I will actually purposefully assess that intra operatively. I think there's something to it. I know some of our colleagues don't really worry about it, so to speak. If you get good alignment, they say you don't have to worry about it. I still do in analogous ankle. I really wanted to create that sort of lateral stability to minimize the risk of of the tales being dragged laterally. I believe firmly that in most scenarios that Taylor's will follow the fibula. If the fibula is allowed to deviate too far laterally, it's gonna pull the tail us that way as well. And so I'm going to fuse the cinders Moses, if that If I'm seeing that. So what I do is I stick a Howard into this in this Moses and twisted. And if I can twist that Howard, you know, kind of so that I could push the people in it and it's moving, that's the problem. I don't really care if it's wide. In this particular case, it was a bit wide. There was absolutely stuck there. There was no motion really at all, and so I left it alone. But it's more if it's unstable, more so than just being wide. That's what I'm looking for. And if you just put a couple of of super buttons across there, is that not enough than efficient? That hasn't been what I've just like you deluded to with the, you know, with agility. That was a real problem. Getting those India's most effusions they could. They would go to non union at times and so on. What I do now is I I will take down the city's most from the front, very sort of very thoroughly get a burr in there, roughing up the bone surfaces quite over, or a length of probably three centimeters from the ankle on up the tibia and fibula. The nice thing is, when you take your bony receptions, you can more slides that it's pretty good quality bone graft because you're now looking for a fusion. If you add some P bgf to that, so you've got a fusion mass that you can work with. I've had pretty good success in gaining fusion there when I need to solve but a couple of screws through a plate using a a north of loch type of plate that I'm using as a sin demotic buttress. If you're a serious a figure buttress, tow, avoid a stress riser in the figure and then crank it down pretty hard. And then, But then I'll have to keep the non weight bearing, which I don't really like to do for the total angles, but no seniors they're gonna be now non weight bearing. And so far that's yelled at pretty good fusion results. But thanks. It's been everywhere. Alright? Anybody else have have questions? Okay, Alright. We'll have time later on. So? So I often get asked How did I get to this point? So I've been doing this like I said before for about 20 years. And and, you know, you get you get to these places as Hodges would attest to you, get your you learned most of what? You what? You know, through failure. So I'm gonna show you a bunch of that here now. But how did I get here? Well, I it was pretty easy, though. My journey with ankle replacement started in a very easy place. I did my residency in the early nineties, and ankle arthritis was a fusion. And that was it. There was no such thing as an ankle replacement. At that point in time. It was a pretty easy skill to learn. You didn't have to, However, I did a fellowship in Adelaide in Australia in the late nineties, and that's where I was first exposed and replacement. That was to the star ankle, not time and take long and suddenly ANC replacement started to make some sense. At least it did to me at that time. Eso I came back to Canada in 1999 started my practice. The only available ANC replacement that time was the agility. I did 10 of them and just abandoned. It was a dismal experience for me and my patients. I had three of those 10 that actually were sort of semi reasonable outcomes, and the rest were not. And to me, that was the matter. If that's gonna be ankle replacement, I have no interest in this. However, around 2000 of Star became available in Canada, and I was very happy to see that because that was that was very familiar with. And so in 2000 and kind of like to think I became an ankle replacement surgeon in earnest over the next, uh, between three and four years, it was did 50 star primaries, and Tim Daniels and I got together and, uh, put our results together and published this and JB Jess with five years ago, looking at our 1st 50 cases with a mean of nine years of follow up and you can see there that there was no way you can. You can interpret this however you like. The results could be okay, but 12% failure at less than 10 years average and 18% polyethylene failure was a big problem for both of us. We really were unhappy with that. And that's kind of goddess looking for something else. So why did I stop using the Stargate with all the policy issues were big among them. But really even more important than the politics fracture than failures was the combination of that and the Austria license that we were seeing. We just saw enormous amounts of this literally. Almost every patient had these large ballooning cysts, and they would, you know, you wind up in these scenarios where patients had virtually no bone stock left when they had failed. This was really difficult. You feel like you did a really good operation that worked out pretty well for a while. And then you wind up in this scenario that was very disheartening. Nevertheless, a lot of good lessons were learned in my experience, for sure, and that is that you know, there's there's always something you can take away from a failure. And so we're going to talk about these little bit one of the sub Taylor fusion. So I thought someday with fusion was a good option to do with ankle replacement. I still do in some scenarios, but here's an example Patient was a significant plane of August foot below in stage ankle arthritis. I thought I could make this look really good. So we go ahead to the big flatfoot reconstruction all in one stage to star ankle and distraction. Some Taylor fusion, a whole mid foot realignment. It looks fantastic. So here we are, high fiving. This is all great. But here we are two years later, later. And things were not great. Not even close osteo isis societies and a lot of pain when we see t and we can see that the subtitle joint did indeed fused. But the tail is completely collapsed, almost certainly from Abyan. For me, dissecting out the tail is so much to get that degree of correction and so on. And that's just it was a really hard lesson to learn. I become became a lot less liberal. Subtitle Fusion When I do something refuge in which I still do simultaneously. I just do a isolated post here for said I leave the Senate Science TRC alone and that's worked out okay, but it really did was a word of caution. And this guy wound up with a TTC fusion. Uh, I also learned the continent gutter pain is a very complex problem, particularly mobile bearing ankle replacements. And this case was really instructive and that this is a guy who's three years out from a star ankle. And ever since he had, he was never really that happy. Always had persistent media ankle pain. You can see all the head or topic bone there. And so here he is. He After a while I talked me into doing something, so we didn't arthroscopic gutted a bride. And I thought I did a pretty good job of removing all that bone there. Arthroscopic. Lee. I thought that was going to fix the problem, but not really. He looks a little better on extra, but he was still significantly painful. We watched him for quite a while. He did not want more surgery. He was never really happy. I think he just preferred to come and complain to me in in a in a deserving way, I think. But here he is, four years out from that scope now. Five. And you could see the bone coming back and earnest here, and he's really got it. Almost captured ankle here, so I thought, Okay, well, we can fix this. And he was at the point where you want something done. So it's seven years post scope in 10 years post total ankle. We took him back for a pretty aggressive open the Bride and Polly Exchange drafting assists. And what you can see here is you can think of that. I did a really good job. I cleared this thing out. There is all kinds of room here now, except what's obvious is that the Taylors has now taken advantage of that and shifted over, moved to kind of where it wanted to go. And he sort of tried to be honest with me. I sort of told me I think I might be a little bit better than with this, but he really wasn't. And things just gradually got worse. And you can start to see what's happening here because we've now freedom up is biomechanics or no longer correct. He's now aligned and it's getting a bit worse. And now he's much more painful. And things start to get some Austin license from Polly Edge wearing and likely some subsided of his tibial component there immediately. And this is what I learned is that that the mobile bearing it's all fine and good for it to be able to float around and find its its home base. But sometimes it won't float to the right place, and that doesn't leave you in a good situation. And it allows the gutters You went with this pain because the Taylors will, but against the Mallee ally, no matter what you do, if it's not in the right place and there's gonna be more coming on this topic in just a few slides. I also learned that Valdas and Delta insufficiency was really risky. And what I said before about how I practice around Valdas ankle stems a lot from this case. But then I was like it as well, so it's a 59 year old GP and colleague in my area of bilateral valve, this ankle arthritis. This was my first year of doing stars that he came along. I remember going to the fast meeting and showing these X rays to all of my really esteemed senior colleagues, all of whom should I go ahead? I'll be fine. Just go ahead and pop a total length and there's no problem. So that's what I did. I put a toll ankle in his right side. He liked it, so I put one in his left side and everything was going along swimmingly for a short period of time. Um, he kind of disappeared for a while, came back four years later, looking like this was completed, utter failure. And when I went back and operated on this that this deltoid ligaments were basically caught his chief bilaterally, there was really nothing there at all. And that really awarded me off pursuing Dogus and dealt with insufficient ankles for a very long time. So you end up with bilateral TTC fusions as a result, and then there's the other sort of simple analogous is bad, but I'm pretty happy with various. So even early on in my practice, sort of Yeah, I can I can handle various pretty well. So I did and took on some pretty nasty looking cases and when this was the zed to for me, which I didn't really have the respect for at that time that I probably should have. This is a patient with various ankle but a plane of Albus foot below it. Thies air complex deformities, then really challenging biomechanics, and it's really important to figure out and understand them and unwind the deformity fully if you want to get any success. So here's this patient can see. She's got both kind of funny looking feet, but her left was significantly worse. And she's got this various tibial plateau faan with an even worse various Taylor Tilton below it. He's got some significant hind foot arthritis, but she's also got this funky mid foot, and we're going to show you that here. So to help understand, this is actually a contra lateral side, which is less severe because it's it's easy to understand the deformity when you look at the less severe side. So she's got this very various hind foot and ankle. You can see the tail is completely overlaps the Cal Kanye's. But because of the morphology of her Taylor head and neck, it's driven her medial column very far immediately. And then she's shortened laterally. And she's got this abducted Platt foot appearance in these ankles. Use that foot. There's that ankle to form is they all have in common the smeared medium alley oler appearance. If you see this, you should be really wary about this ankle. This is not the standard thing. So what did I do with her? Well, this was back in 2000 and three s. So I thought I think I know what I'm doing with this. So I took her to your for two stage procedure in an open ankle release. True mid foot osteo autumn of the medial closing wedge and slightly planter closing wedges. Well, to try to recreate arch and rotated around the triple Arthur thesis to complete that. So I thought I was pretty good there. And then a few months later, we took You are and did a star ankle and a modified Evans lateral ligament reconstruction. I thought everything had gone well, as you can see, a old crappy X rays here, and it didn't take very long. And she had some recurrence of this various deformity. And that happened. I couldn't quite figure it out, but I took her back to the O. R. And did a lateral eyes in California lost theology. That seems like a reasonable thing to do. That's, um, toe work at the same time, but not surprisingly, that even though I thought it looked good in the O. R didn't take very much longer after that. Another, not even not little over half a year. And she was having this recurrent Barris yet again. You can see the polyethylene being injected into the fibula there. That's clearly not a good scenario. And so I did what took her back again and said, I got through this medial side of the problem that this media release redid the lateral ligament. Reconstruction fought. Finally got this thing really sturdy, however, that didn't even really last two years, and she developed this very severe. Various ejected the poly, and I felt I had to go and revise this. So I revised your Taylor. Come on, the tibia was still solid. There were no really good revision in implants available at all around that time on dso, she wound up getting I had adopted integral by that point in time. So I put a integrate Taylor component had to cut it very low, like you see here because of that degree of bone loss, she needed extra thick polyethylene. There was no such thing. So she wanted getting I put in 29 millimeter space or stacked on top of each other and that little metal plates holding the top one in place. That was a temporizing move until I could get in a custom made 18 millimeter Polly that I put in a second stage of a revision, which is what you see here and that all did okay. I was a bit surprised in a way that she did. Unfortunately, she was very lovely woman when she passed away in a few years ago, she died 12 years post revision, and she was actually very happy with this and that stayed like this. These are the X rays from shortly about a year before she passed away. But she still got this residual foot to form. It took till quite some time afterward. I really figured out where my errors were here and what you realize when you see over here on the left hand side, you could see the center line of her tail is really should be pointing out about the one dash to inter space, and it's not. I left her foot way immediately translated. What that did is it placed that center of 4 ft loading every time she stood on her toes. She had this medial 4 ft load causing this rotational moment around her axis around the ankle axis, driving into various. Unfortunately, this was a robust enough construction that put up with that for quite a long time. But that was a really guarding situation, and she clearly did not correct the foot to the level that needed to be because I didn't understand it well enough back in those days. So caution around the deformity is really what I'm trying to tell you. I also learned with the stars that anchor replacements and young patients can be okay. So trump contrast into what I told you before. He's a 45 year old guy with bilateral ankle arthritis. He's got to spontaneously fused feet. Eso nothing moves other than his ankle jiggles a little bit, and here he is now 16 years post off from two stars that are still working out very well for and a 61 years old now and still going strong. So hopefully this is going to carry on for a good long time. He's clearly a low demand guy. You probably weighs about £100 feet tall. If that. And so in some of the scenarios, you could get a very young. So in 2004, though, I moved on. I've had enough of the star and right medical. This is kind of interesting twist, Right? Medical was the North American distributor for, uh, New Deal, who owned the Integral ankle. So right, Medical brought bed Linderman and Bruce Cohen, who we recognized to Vancouver to demonstrate the Integra. Bruce had actually never done one Onda be its description of his journey, really emulated mine with the star ankle and, you know, actually became quite good friends around this time, A Z. We kind of worked a lot of work through a lot of the same problems, and I was convinced to change his other calling. The victim of their abandoned also became a good friend of mine. He was then doing a PhD in Calgary, so he came to Vancouver to assist me with my first two integrates and this is my experience. I did 240 integrates with a much improved a visionary. I was actually quite happy in general, and that's why I stuck for quite a long time. But there were still big concerns that osteo Isis again was a big part of this thin Polly mobile bearings, persistent pain in the gutters and unnecessarily complicated procedure around the tail us with poor instrumentation. And so my lessons were difficult. This is a patient of mine. He's a neighbor and a good friend. Hey, had this Integra done at five years was doing very, very well. But he had this osteo license, didn't wanna further surgery. Didn't take long when you had sudden, acute onset of pain as his tailor's fell into the sinkhole that was created below it. This was revised to an ingrown tube that got me the point that those kind of cases I had many of these on the in bones were always there a salvage when I became a really big fans of in bone, and that's where my shift that began. Come back to that in a second and I learned a few other lessons from the integrator and mobile bearing pain was one of them. And so this is a 64 year old patient two years post off. She always had this persistent got her pain much like that patient with a star that I was telling that despite excellent looking X rays, though, so she didn't have all that hetero topic bone. Nevertheless, she was having trouble, so I figured I'll take her back and doing arthroscopic gutter to bribe me. But she just got worse. It was only after I finally took her back for an open to bribe meant that the light came on. If you look at what's happening here, the way that that Taylor's is moving, that is nowhere near normal mechanics and the light came on when you look closely now that the suspect stand to paint the area that's lighting up, particularly immediately is not the gutter at all. If the media malley Olis and what's happening here and what happens with these mobile bearings that are actually working really well is a developmentally or stress pain, it's like a stress fracture in sight. Unit more you free them up the worst they get and that was a real disappointment. It's always frustrating. You do an operation you think looks good and should be good and just isn't when the when the design lets you down. The other thing I learned was being very vigilant, especially with the tailless s, is very similar case. What I just showed you before they're good patient of mine. Austral, Isis and the tailless Salty, bonded in the front and one day just suddenly got worse when it's pegs snapped off on this cantilever diving board over the pool in the back of the tail is here and you can see there's pegs snapped right off here on the right hand side and they're stuck inside the tail is there. We have to dig. Those I was in order to do is revision. So that led me to a point where I felt I needed to move on. And it was sort of serendipitously through my long ties with the right medical in Canada, through the Integra and me, pestering them all the time for better ankle replacement, together with rights, acquisition of In Bone, which I had developed a bit of a love affair with a brief way that led to a confluence of good events and high together with Hodges and the 500 surgeons were able to come together to form rights. Total Ankle Development team. Back in those days, you'll notice the picture of the right logo looks quite different back then. That zoo over 10 years ago now, and that leads us to where we are now. We've been ableto developed, some pretty impressive, I think a pretty impressive array of devices that help us cover the continuum of care and get us to where I showed her to talk to you about at the very beginning of where I am now. Thank replacement. And so it's been a long journey. 20 years. It's hard to encapsulate in a short talk like this, but that's where we are. I think I'm gonna jump now into some cases for discussion. We've got about 15 minutes or so to do that so quickly we can get through some of these, but I'll pause there and open it up for some questions if there are any. Yeah. Uh, Murray? Where's Avery? I wonder Murray Hodges. Okay, So, Adam, Adam, you want to start first? You have you have a question. Okay. Um, Murray, you talked about the zed foot. Um, or, um, or I hear people calling that the ping pong ankle. I can't remember if that Steve or Dim Daniels deal, but longs. What's that? It sounds like a tin is, um yeah, so long standing various. Um, they have a valdas foot, and you've got to do something about it. And, uh, and I think that this is something that we've all discovered Is that just fixing, uh, the foot the ankle on Lee gives you? You're only halfway there, Which is the reason why we're doing a lot of these in two stages. But have you Have you found in the in the two part ankle? Um, that doing this kind of big deformity, you have much more confidence in it, Or do you or do you feel like, um to part three part? It almost doesn't matter. So that that's clearly a guiding question. But I think you're absolutely right. The I went from being an absolute, you know, Askew, well known. Those meetings, you know, early on, pounding my fist on the table. It's God. We've gotta have a mobile bearing option and I think, thank God I was surrounded by smarter people than May. And I think that's just a flawed concept. And in these cases in particular the stability that you can gain through a well designed sulcus articulation or in the articulation it provides some level of inherent stability but still accommodates potential off Axis forces is just way more forgiving around these very complicated ankles. And so, you know, in bone for me has been, uh, just a game changer for these very these very cases. And actually, it's what I just threw out there. This very first case just happens to be a said the former case Andi. I think that it's, you know, the stability that you gained from having ah fixed bearing two part type of ankle, but with it's not just that, it's the geometry of the articulation that matters as well. So I think I have a lot less competence, say, within Bone one in this scenario, not because of the bone implant in her face, because that saddle design did not impart quite the amount of stability I would have wanted to see, um, in some of these kind of cases, but the and and again, you can see there's a convergence. You know, I guess, um what's the imitation is the sincerest form of flattery, right. So I think you can sort of see that. That's the that has borne out to be, uh, articular geometry that does that that works. But you remember, Remember years ago that what we did first and with the design team is is converted in Bo wanted in bone to with the tail articular geometry. Um, you showed a couple of pictures on the long taylor stem. Just a quick comment on the long tail of stem before you because because I think this is a great case that illustrates so much what you're talking about. So long, stem taylor component again. We and I think I could include you in this too, I think all of us, I think initially thought that was a really good option for, uh, you know, salvaging the complex Taylor failures. And I think all of us were disheartened when the f d a, uh, pull the approval of use of that. It wasn't. It was It always remained available to us in Canada. So I used it a handful of times. And as it turns out, you know, this is one scenario where the FDA was certainly right. Uh, the we saw some tremendous failures related to that long stem. Um, some of them You think Mike Bradley's got some wonderful pictures of trying to pound a long stem out of the foot? Not necessary that one. But it's one of the ways that that causes grief by really binding to bone heavily. But the biggest issue is that bonds to bone and then stress shields, the tailors and the tailors just melts away underneath the tailor component. And that's something that we don't want. We want load sharing devices, not load carrying devices, and and the long stem and the tail is has proven to be not the right step in that way. Yeah, my experience in the four long stems that we were able to place before the FBI shut those down. 100% of them failed. The tail has failed with stress shielding, and and so, yeah, we were frustrated. We almost sent right down the I. D. You remember that discussion all You gotta do it. You got to do it. And that would have been a phenomenal waste of resource is alright. Any Any other questions, guys? Nobody. Okay, well, let's keep going and we'll be looking for question. If you do have a question, either either, um, chime in or you can raise your hand. Um, which is there's something on this that you can raise your hand, but But it's down at the bottom of your participants list and you go raise your hand like I'm doing it for myself right now. Alright, on. I'd also say you'll be for all of you. Feel free to amuse yourselves if you just want to jump in with a question as releases now case discussion time. It's a little less, uh, formal. Hopefully won't feel like you're being preached at quite a much, but this is This is an example of a said to formally case, but a much less severe one than what I just showed you. But it sort of illustrates my current approach to this. Now this is a 75 year old woman. She's had a severe ankle pain for quite some time. She's got this significant various on her left. When you look at her, I don't have a photo. Unfortunately behind clear various, uh, on stance. She's got this. You can see on S a p view that I've drawn the red lines there She's trying hard Thio compensate into Valdas through her sub hair joint. But we can't get all the way there. But more notably in the lateral views he's got these weird bilateral collapsed, you know n c level mid foot breaks. You could argue that maybe this represented a cable Vera foot that collapsed through bone. But she's telling me she's had clapped feed her whole life. So she did. I asked her in many different ways. And where your high arch person ever at one time? Absolutely not. Never. Never, never. So, nevertheless. So she's got this developmental foot alignment that puts her ankle into various for hind foot into some degree of compensatory August. And with this mid foot driven playing analogous deformity, the question is, how are you going to approach this? Now you can kind of imagine looking at these X rays here, if you twist the tail is to be neutral to the mechanical axis. Where is the foot going to go and what you're gonna have to do the foot and again if anybody wants to ask a question or jump in or maybe offer some input as to what they would do in this scenario, by all means, I'd love to hear what your thoughts are as a group. And that being said, you know, Murray the difficulty. Yeah, The difficult thing about these is what do you do first? Because, you know the foot's gonna be an issue. Embarrassed. I think it's often easier to do the ankle first because it gets you straight. But, you know, you're gonna have to do some kind of variant of of a fusion or a nasty autumn E in the in the navicular Conair form and you're in the list. Frank's joint. Um, yeah, these are a little hard, typically with various. I like doing the ankle first and then and then dealing with the other. But this might be one I might stage and get the various corrected and then pin it and then fix the foot and then and then put some cement pond, then come back and do the the foot later. But I also think this is probably one, um, that I probably could do in one stage, depending on I'd looked at the CAT scans and other things. And you know, when I look at this based on my sort of evolution through these, with embarrassing with with the more typical various, if it's a if it's a really severe when I'm sure you're going to see the next case with a cable, various type of foot, those ones I will plan to do in two stages. But they're all commonly do the foot first with realigning the ankle as part of that first stage, but not putting the total ankle in then doing the foot. And the reason I do it that way is just because the it gets there. The fusion part of the surgery is where they're gonna have to be non weight bearing and minimally active when I put their total ankle, and I want them weight bearing and moving quickly to get there to maximize their ankle functions. So I want that to be, hopefully an isolated procedure, and I want them to be ready to go, so I try to do their foot first. And so in most various stick typical Barris. That's kind of how if I need to do it in two stages at all, which you don't so common you have to. But if I do, then I try to the foot first. But in this particular scenario, if I see is that that for me like this, these all get done ankle first and you'll see why in this particular case. So the reason they're being that I don't know what I'm gonna do the foot until the ankle is straight and I just tell the patients, Look, it's gonna be a longer recovery for you in this way because I can't do your foot until I know where your ankle is gonna be and how well you're a total ankle's gonna function. So this is just another view of her X rays here, a bit more comprehensive view of everything here. She's also got some sub taylor arthritis there from all that long time compensation. This is the prophecy plan. The one thing I'm gonna highlight here and draw everybody's attention to up in the upper right hand side. I'm gonna circle there with my most you can just see to get the Taylors where it needs to go. How much of the videos in the way. And if there's anything that I can leave you with, is various. Ankle correction has almost nothing to do with what you do on the medial side of the ankle. And Hodges will laugh because I used to be all about medium Al Eola, rosti, autumn ease and everything on the needle side. It's all about what you do here. This already for gotten that that states that you went through what you really if you fix this, if you get if you create space for the tail is to move into by getting rid of the fibula there as I'm drawing there, just follow that in Boehner section right down. It'll just fall into place nine times out of 10. So that's what was done here. It's a bit of leaks you can't quite see. The cut does go right down like that, and here she is after stage one, and you can see that haven't really done much else. But funnily enough, I had her all teed up to go for stage two and she absolutely refused. She said No, I love my ankle. I love my foot. I can't figure out why her foot works. Um, but it looks compared to her pre op pictures. I guess there was more flexibility there than I appreciate it. And so she is. Now it's actually this slide decks a couple of years old. So it's about five years out now. Looks like this. And they're still going strong. So I've never been able to talk her into a stage to procedure yet. But this is why I think when you see the said that for me is one of the other reasons to think about the ankle first. So look for that smeared ankle on the media. Mallia. Let's look for the funky foot position and then think about doing the ankle first. That would be my two bits. Murray, in other part of North America, we call that Charco, But it's fine. Jason, do you have Ah, you have a question? I see your yourself. Yeah, Yeah. No, no, thank you. I have two questions. Number one, uh do you Do you pay attention at all? Thio? I mean this this cable various may not have had it, but when they when they have ah severe external external rotation deformity and the fibula is way posterior. Um, what do you What do you do with that? I had one recently where they were the prophecy. Put the rotation about 55 degrees. I think I even sent it to Hodges and he responded back. But what do you How do you deal with that rotation? Yeah, so alliances that question. But all in all, sort of show you as well, because this case, it's just I popped up on the screen is exactly that. Eso the the classic cable various foot kinda like you see on the screen here is typically associated with external tibial torch. And that's quite considerable, and I don't think you can really address that through the ankle joint per se ever so slightly. You can, but not not mostly. And if it's bad enough, so what I will do is I will make the foot and this is a This I kind of learned this by spending some time in Germany and with a guy who cracked some of the most twisted up feet that I've ever seen was Wolfram Vents, who's a friend of Hodges in Line and Heywood untwist. He's just remarkable pretzel feet and it was that was there when I sort of saw this done. When you really straighten out these cable Vera's feet yeah, they point the The actual foot is typically lying in 60 to 75 degrees of external rotation once you finally get the foot straight to the ankle. To catch then is that the ankle needs to be made straight to the knee, and so he would routinely, just very, in a very typical kind of German surgeon. Fashion very quickly. Just cut the tibia trans verse Lee and rotate it 50 degrees internally and fix it with K wires and wait for it to heal. I haven't done that myself. That's a little bold, but I will do rotational. I don't have it in this slide deck, but I will do rotational tibia. Lost the autumn ease Thio. Bring the the and the fibula, of course, with um to point the ankle in line in the appropriate alignment with knee and then adjust the foot below it. So all right, then that, and saying it that way is wrong. I'll always do the foot and ankle reconstruction first, and if the foot is then left in massive external rotation. Then I'll go back and do a tibia osteosarcoma to straighten that out on DSO. I won't try to overly correct that through the through the ankle replacement. I'm gonna follow the anatomy that's there and then correct above it if I need to. I hope that's sort of clear. Yeah, My my experience is you just really need Thio. Be sure when you're doing your tibial reception that you that you don't get thrown into too much external rotation and that with prophecy that that can happen with this in particular. Um, if if the fibula is so posterior translated once you get the tibia right, the tail is typically will come around and and so so that. I mean, that's how I I fixed that at least try to fix it. Process. You can help. Yeah, I encourage you. Look at this view. So in this picture here, this back that said cases to illustrate, um, it's not just the rotation of the, uh what what prophecy can do or where prophecy can kind of mess you up is in this gutter by section angle that they create. So if the fibula is truly lying far posterior. But not only that, it's actually externally rotated relative to the plate. Faan. Then you'll get a very wide gutter angle. So in this one you can see is 7.8 degrees, and I've purposely chosen to internally rotate the tailor, the tibial component. Like I said, I don't There's only there's a limit to how much rotation you can correct here. I'm trying to correct a little bit here, but there are some of them where there's, like, a 25 degree angle here, and you split it to be 12 degrees. Well, that's gonna make it way too externally rotated. I get very nervous. If this area here, I'm sort of hopeful you can see my mouse there where the 2.0 is at the bottom center. I get very nervous if that number is about five degrees. Ah, if my act, my tibial component is gonna be pointing more than five degrees external to the medial gutter line, I get nervous. And so I think that sort of speaks to what you're talking about there. Is that the If this anatomy and this view looks like a normal ankle, then the relationship of this to the proximal tibia that's tibial torture. And then, uh, and Andy Goldberg's recent paper. He showed that pretty well. And you can't correct this tibial tor shin that you see here at the angle that you that you either you either accept it or you leave or you correct the tilea. But if what you're talking about is the gutter by section angle pushing your implant very, extremely rotated, yes, that I would correct through the ankle, I hope I hope that I hope I'm being clear there to me. Of course, I'm clear, but I'm not sure that comes across period. Anybody else. But there's two different ways you can wind up with excessive external rotation. One in particular, torch in one. It's regarded by section problems guarded by section problems you can solve at the ankle level. The to build torch in you can. I hope that's relatively clear. Um, jump ahead a little bit. Here, by all means, will jump in with other questions and things that that's fantastic. So eso here's a different style of various. This is the more typical kind of various cases of severe cable various foot below of various ankle, much more typical little complicated way less complicated than set foot Mhm. And so the question is, you know, what do I do here? Well, when you look at the deformity, these are the things that need to be undone. So this is going to get a dorsal lateral closing. Wejust iata me with the rotation of the foot. Andi, that's done through a big We're not a modestly sized lateral approach to the to the foot, and this was done in two stages. So in the first stage, we're gonna do that. Osteo autumn E we're going to realign the ankle. I pin this one straight. I've tried using the cement technique that Steve talks about never not been quite as happy with. That is just simply pinning it. So I just do this now and and then doing this mid foot and hind foot fusion, and then we're gonna do a little bit of toe work if we needed to down the road. So we got him aligned here, and that just set us up for a nice, straightforward in bone total ankle. And when you rotate the leg correctly, you can see that the ankle itself is actually perfectly normal. It's just externally rotated relative to the knee. And so we have cleared out his lateral got her. Like I talked about making the correction of the various very easy. I didn't have to really do much of anything. Media other than just the usual clean up in a little bit of medial deltoid release. And here he is now a year out on very happy plan to grade foot. And you can see I've got a very mortis ankle X ray here to get a A p of the implant. But that's again because of the typical torch in. But when they account for that on the X rays, you can see a very nice, normal looking fibula position in relation to the ankle and foot. That's so I didn't go back and do a TV lost iata me here at the rotation of the automotive because his foot position, once I had taken the huge wedge out of this foot, looked OK, and I think I have Ah, I'm not sure I haven't thought this Ap sort of shows you that if you look down the line of the tail is now I'm pointing at his first Ray like you should be here. And when you get that straight, then then you can kind of get the footage. The right alignment to the tibia. So this is in my hands. This is always done in two stages, Hodges. I don't know. What do you do these in two, or you do them in one? Uh, no. I do him and I do him and, uh, most of the time and to if I'm going to do a triple, I'm gonna do him to, uh the the only thing that I will tell you is that if I do this much, work to the tail us? Um, I am I am looking very, very critically at the CAT scan, and very often on will use an envision Taylor's on these, Um, I use it more for Valdas, but But I do use it for various and so So I'll do the CAT scan. And if there's any avian looking stuff at the at at the most superior portion, then I will. I will get the prophecy scan toe, take three more millimeters off, and I'll put in envision e I like that, too. In this case, I felt I had pretty good bone there. And so it looks great work. That thought process is Well, you can say I added in a little Doris reflection First Ray osteo to me just to ensure that I got his 4 ft plant a great here at the time of the bone. Alright, So Murray, you got you got time for one. Your options are osteoporosis, Val Ghous or a fusion take down. Why don't we not to the fish and take down because that's gonna be a topic for later. And I think the osteo isis cases is an awesome case. You could talk a bit about that. You get a Z. You said there's gonna be a complex primary discussion in other sessions to so the analogous case can wait. Um, yeah. So this is actually a pretty It's a very short in the straightforward case 88 year old the woman who had her ankle done in Ontario by a friend and that had a good job, had a great outcome, no symptoms, very happy. She was just sent along to me just for routine follow up. So the first time I ever saw her at six years post offices what her X rays looked like And you can see their smallest you license there, underneath the tail us. I let her know that I was a bit concerned about that. But she was 88 I was like, Well, I think we're just gonna leave you alone. And she was very happy with being left alone. However, I told you you should come back. So she came back Now 90 years old and two years later and you can see that might have been a bit of a mist ake Her tailless now is almost an eggshell Ostpolitik Legion is now much larger on C T scan. Here, you can see it's gonna just moved through there and you can see it's occupying a very large portion of her medial Taylor head and neck and Taylor body. And that was a question. She was still completely symptom free. Based on my experience that I showed you before leaving these patients with a sinkhole below there, Taylor component was just didn't feel right to me. And you have to ask yourself, you know, a surgeon, what would you do? Hear a completely asymptomatic, otherwise pretty healthy 90 year old woman who's eight years post tar and she's got that. What would you do? So I thought long and hard about it, but I really want to go in my note or pelvis or RIA. Her femur probably wouldn't be any bone in there, anyway. Fill it with Allah. Graph chips that may or may not osteo integrate we thought about. I talked to a few people, including Hodges, and so they came to the conclusion that I would do something. I actually don't comment because I almost always want a bone graft these. But here's what idea. I put in a whole bunch of pro dance and fill that space right up, and here she is. I think this is only six weeks out. I do have a later extra. I couldn't dig it up in time for this, uh, this presentation. But most of that has visibly re Zorba now on the last extras that I have, and she's remained entirely symptom free through the whole thing. So I haven't really see Teeter to really know if that turned into any degree of bone or whether it just re absorbing turned into nothing. Um, it definitely doesn't look completely like normal tailless yet. But so far she hasn't fallen into the cavern. She's now about 91 years old. That was about a year ago. I did this and seemingly doing okay. And for me, that seems like a reasonable salvage. But it opens up the question. What do you do when you see these massive Ostpolitik lesions? We did change your Polly at the time to and just by way of interest finding, um, in bone one polish. Not an easy thing to do, but we did find some on that. We were able to put that in there, and so hopefully this will carrier for the rest of her of her life. But we'll see how we go. But way have about about 60 and bone ones and and we've seen this on the M bone ones. It was seen indications early on the M O twos, but but much less coming. And so I do believe that it has something to do with the, uh, with the inherent instability with the saddle design. Um, in the Polly's, when you take him out, they look, um they looked not what you would hope s O. I always hope that the that the tailors is loose so I can at least put a tail us in before I build up below. Um, either way, and then you can use in bone to, But I think this is This is a great solution for for a really difficult problem. Yeah, you know, I like I said, I wish I did have a CT scan to check on how she's been doing. It's pretty hard to justify doing that in a truly asymptomatic 90 year old woman, but But it would be interesting to see just how much of that's actually been turned into bone versus just, you know, kind of turned into more reinforcement. Maybe maybe the surrounding bones has become more sclerotic and supportive. I'm not sure, but, um, in either way, it's been a pretty good salvage for her, and I think I throw that out. There is at least an option to consider for anybody else who's looking at a similar kind of case. Beautiful. Well, I think that that is, uh that is great. I'm telling you that the nuggets in your presentation, Murray, always make me love toe here. You any any questions at all from from the group. Um, you know, you put everybody to sleep? No. Well, uh So, Nate, I might get you to finish up and talk about about the next, um, program And who's gonna be there, And, uh, and guys remember, um, you have my email address. If anyone's got questions, please send me an email, and, uh, and our group can give you Murray's email address also. So moving forward, we want this to be a collaborative, Um, open discourse. So night. Yes. Well, first of all, thank you, Dr Penner. Again, that was a fantastic talk. Really appreciate your time with everyone this evening and and just for the group on here. Aziz, Dr. Davis mentioned. So the next step is for us is gonna be, uh, sort of the part two on our primary Siris of weapon. Ours that's gonna be in early October is what we're gonna be shooting for. We're still trying to nail down faculty for that. So as soon as we have those details, we'll get that out to all of you. So just keep an eye out for a communication on that. And again. Thank you. all for joining us this evening. Really appreciate your time. And you all have a great evening and a great rest of week. Thank you.