Dr. Robert Anderson and Dr. W. Hodges Davis discuss the history of porous metals in orthopaedics and why it matters in total ankle replacement. In addition, they share their early experience using the INFINITY™ with ADAPTIS™ Technology System.
abilities, and I'm the senior director of right medicals Total ankle marketing program. We are very excited to have you all here to discuss the latest innovation in the total ankle segment that's infinity with adaptive. This system will be going into full commercial launch this month. So the incorporation of this new adaptive technology has really been in the works for over 10 years and through some recent advancements and manufacturing technology, a lot of hard work across the globe. We're very thrilled to provide you with the markets. First three D printed total ankle system So during tonight's Webinar, our surgeon faculty will walk you through the various enhancements. They've come along with infinity with a Baptist. Some of those include it being designed for optimized for bone in growth. Additionally, it is increased initial implant stability and with the incorporation of Everlast highly cross linked polyethylene, it has improved wear resistance. So along with that, our faculty will also provides a detailed commentary around the role of porous medals in orthopedics, as well as share some of their early experiences with this new prosthesis. So we're very fortunate to have two highly experienced total ankle surgeons with us tonight as faculty and presenters. As our first presenter, we're fortunate to have with us tonight. Dr. Robert Anderson from Belen Health Title, Town Sports Medicine and Orthopedics in Green Bay, Wisconsin. So Dr Anderson is the founding orthopedic surgeon for the Ol Miller Foot and Ankle Institute of North Carolina in Charlotte, North Carolina. He served as team orthopedist to the Carolina Panthers from 4017 and now is an associate team physician to the Green Bay Packers. He has also served as the chairman of the foot and ankle subcommittee for the NFL since 2000 and three. It was recently named the co chair of the NFL's Musculoskeletal Committee. Dr. Anderson is a past president of the F A s co editor of the ninth edition of Man's Surgery of the Foot and Ankle, former editor in chief of the journal Techniques and Foot Ankle Surgery, associate editor Review for J. B. J. S, J. W. S F. A. I. A. J. S M. And numerous other peer reviewed publications. So, Dr Anderson, thank you for finding the time to be with us tonight. In our second presenter is Dr Hodgins Davis, who joins us from North Carolina in Charlotte, North Carolina. So Dr Davis has been in practice for over 30 years, has authored over 160 publications on the topic of foot ankle surgery. And throughout his career, Dr Davis has been widely recognized as one of the most experienced thought leaders in the total ankle space, implanting over 850 today. Dr Davis also happens to be right, medicals chief medical officer. And he aids us in the development of new technologies, services and medical education programs for foot and ankle surgeons across the globe. And so we're glad to have Dr Davis with us this evening as well. So just a few Zoom housekeeping notes before we get started. So all attendees accept the two presenters will have their audio and video muted for the duration of the webinar. There is a Q and A button on the bottom of the screen, which you can use to type questions to our presenters. Our faculty will monitor those as we move along, answering as many as they can before we conclude this evening. And finally, please know that this webinar is being recorded for later use on a virtual learning center website. Again. Thanks for joining. And we'll go ahead and turn this over to Dr Anderson to get us started this evening. Dr Anderson. Thank you, Chris. And hello, everyone from Green Bay. And it's a true pleasure to be back working with my longtime friend, colleague and business partner Hodges in presenting this, uh, webinar to you on outlining some of the new advances with the Infiniti total ANC Arthur plast e eso. Without further ado, we'll get into my presentation. Yeah, just trying to get the slides to advance here. Here we go. And these are my opinions, Not necessarily those of right medical. And I'm sure same for Dr Davis. So I want to present to you my experience utilizing the new adaptive technology on the already successful Infinity Total ankle. Arthur Plast e e. I want to thank my repent because many of the slides that I'll show you in regard to the adaptive technology I adapted from a recent talk that Murray provided in end of July to the salesforce of right medical. Now, I've had incredibly great experience with infinity. We've been doing this since 2010. I was privileged to be part of the design team. And in the premarket trials, I've done over 200 Infinity total and forth. Classy since I've only had four or five revisions of Infinity total ANC Arthur Plast Ease I have used prophecy navigation on all but the first four cases that we implanted an affinity total ankle in eso again, great success prophecy, navigation all by the first four cases, and I'm a sort of a sham for guy. I like the sham for Taylor's in all cases where there is adequate bone available. So again, if there's not cystic disease, adequate bone stock, I prefer the sham for on those cases, and that's been my go to. It's just an example of where I've had great success with the infinity. This is a high level, 43 year old former professional woman's soccer player who failed multiple surgeries for a Nostra consolation. The tailless underwent a calcium phosphate injection. Unfortunately, a lot of volume was placed into the tailless, and from that she developed a vast necrosis of the tailors as well as a persistent Ostro Contra lesion. Um, insist of the Taylor Dome and you go, what do you do with? This is a very high level, athletic individual that now has ah, difficult to salvage situation. And, uh, we did salvage this with the Infiniti total anchor. The plastic I bone grafted the defect in the tailless, and we placed a flat cut Taylor component with the Infiniti tibia. She's now 18 months out, and she's pain free, doing very well. So again, great results that I had with infinities over the last 10 years. So Infinity will works great. But can we make it even better? And that's been a question that our design team, including Dr Davis, have approached with the engineers right medical for years. How do we make Infinity even better? And that's where adaptive technology comes in with its new features and include, uh, the ongoing, low profile, resurfacing type concept now with pores in Growth, a new type of polyethylene implant that is more highly cross linked and new Taylor options as well. And I'll go through all this a little bit later. Our main priority when we're talking about trying to upgrade the Infinity was, How do we get better in growth? How do we get immediate stability and We've always known that bio foam commercial titanium coding would be beneficial on the infinity total of ankle implant. We recognize it's great potential for enhancing bone in growth we wanted in 2010. But in 2010, 10 years ago, the technology wasn't there to place bio foam on the infinity implant. And again, this was one of our, uh, in house memos that we were writing at the time saying that Listen, we want to big design changes on infinity over the next few years. One is bio foam, the other is props. Interpretation. We've had prophecy since that time and bio foam now is is here's it's been 10 years in the making, but now we have our second highest priority that we recognize in 2010. So let me just Segway a little bit away from the new Infinity. Adapt is total and Garth class and talk a little bit about why is bone growth bone in growth important? When we start talking about our total ankle implants? Well, you know, just give you a little history here. The first generation of bone and growth was actually just a surface treatment. Something provided a rough surface for bone and champ attachment. When I was coming through my residency, we're talking about centered beads and plasma spray and acid etching, and those were back in the eighties and early nineties. And then the newer trends, though, now were devising medals that allow for bone in growth not just on a surface but through an entire device. And most products that have some type of bone and grow surface have been developed for implant fixation surfaces such as that for total joints. But you also see it in spying, craniofacial dentistry type applications as well. And what's interesting is that nowadays our products that do allow for boning grow thick, cut in almost any shape and can be centered onto the underside of a titanium implant substrate. But again, how do we do that? Is technology there to do that with total ankles? We've seen how pours in growth fixations revolutionized hip replacements. Bill Heller's Harrison Boston, you know, talked about this years ago about how pours in growth revolutionized hip replacement, came toe the federal stem, and then this quote from University of Florence by Dr Mattel. See the development of course medals for osteo immigrant integration has revolutionized the field of orthopedics. And really, it's not just total joint reconstruction. The field of orthopedics has seen the benefits, of course, in growth medals. Now our newer methods are now changed out. We now know what exactly is the ideal porosity of a metal that promotes bone in growth. Um, the ideal is somewhere between 1500 but fourth pedic applications. It's usually somewhere around that 406 100 size porosity. We know that our metal in growth materials works so much better than hydroxy capitated ceramics. They're just too brittle toe work, particularly as we talk about total joints or larger applications. So again, we've seen more recently metallic graft applications for Born, both voids, really, in place of structural graphs, we're seeing people use metal now in place of auto R Ala. Graft type wedges and, of course, is to be very useful in revision surgery. There's a lot of types of metal of available. There's Trebek, your medals, uh, the so called titanium, uh, tantalum. And there's the various titanium alloy is there's commercially pure titanium, which is bio foam, which right medical has seen huge advances in over the years and proven success. We'll talk about that in a few minutes, and there's many other types of titanium alloy is that could be used with titanium plasma spray over the top, where the roughness will promote bone and growth. And then there's even now Rebecca metal vascular closest type screws that available in the marketplace. So we've seen a huge surge in how we use pours in growth medals in orthopedics, particularly foot and ankle, over the past several years. Now. Bio foam, though, is something that I know very well and have used it for many years. This is constructed of basically commercially pure titanium. Uh, it's 60 to 70% fully pours in its construct, and again it's in that average pore size of 500 which is right where you want to be when you start talking about orthopedic applications between 406 100 microns of ferocity, it's got great compressive strength. It's got a module is very similar to that of Trebek color metal, slightly higher coefficient of friction, which helps with initial stability, as we saw when we were using a lot of the bio foam wedges for Evans and cotton applications that you can place these devices in, and they got immediate stability there. Friction quote there. Friction coefficient was very high and amazing how stable they were right off the bat on. They did a good efficacy, just like Rebecca Metal did, uh, seen through extensive animal attesting. This is one of the first bio foam white papers produced out of Russia protesters. Hospitalists was an animal study several years back again looking at how successful the in growth was with the commercially a pure titanium. That bio foam is in the animal study here, where they use the Pataxo canine model. And they compared titanium versus centered beads six weeks in life, looked in astrology and found that there is a tremendously better in growth on the commercially pure titanium, which bio foam is than in the century beads. So 32% more calcification in within the beads themselves. So again, many studies have been done comparing beads to the poorest metal, the bio phone, poorest metal and even compared to Tribeca metal, and found that again, Um, it's very, very similar tobacco, metal and much better than center beads when it comes toe true, bony in growth so We even got so far that we in Charlotte Hodge and I were part of this study. We actually went and did CT scans of all of our patients who had a bio foam Evans wedge placed for flat foot reconstructive purposes. And this was a study a few years back that we put together and again we had 26 patients that we identified. We had 19 with all the C T scans and statistics we needed. Average age was about 56 or older people. We used additional bone graft in five patients on supplemental fixation was used also in five patients. But for the vast majority, they did not have supplement supplemental fixation and what we did again, we did CT scans and all these people. We found that there was tremendously good bone in growth into that large metal bio foam wedge. R C T scans show that all of the patients had some bone in growth. Some had partial, some had salad in growth. Um, but fortunately, regardless of his partial solid, that had no difference In some of the secondary measures that we looked at. We found that the cost of using this metal bowel foam wedge was very similar. The cost of Allah graph and also reduced over time. We didn't have to worry about prefabricated the wedges. So at that point in time and again, this is several years ago, we knew that bow phone was going to be here to stay. It was a very, you know, strong medal of one that really had affinity towards bone in growth. And again, how do we put this on our total encarta plastic? This was again something that dates us back that Hodgson and the design team in the engineer said, Listen, we know about phone works. It works great. We can see these large metal wedges that attracts this bone and growth. Now let's put it on an underside of a typical or taylor component with our total ankle Arthur Plast E devices currently available and again. And when I said that, we thought about this in 2010. Now, here we are, 2020 and technologies finally caught up. We now have the opportunity to do this. So this is the adopted adaptive technology merging with the infinity that we've already seen great successes with over last 10 years. This new adaptive technology includes three D printed implants in gross surfaces with bio foam. It still has the ability to use your prophecy. We have a new polyethylene upgrade that we'll talk about. We have both the sham for and the block flat cut Tagus opportunities and, of course, that interchangeable continuum that right medical has been known for with all of its total ankle implants. Eso What is adaptive technology again? You got to think of it as a 2020. By awful. It's a porous three D printed metal. It could be made in any shape, thickness of infinite variability. And so really, we could do anything we want now with these three D printed medals and the poorest surfaces that we place on them and you go, why is this important? Well, again, Just like Chris said in the introduction, this adaptive technology with the biofilm edition not only improves long term fixation, so we're seeing that if facilitates bone in growth is earliest four weeks post op. But again, just like we saw from the vile foam Evans wedges for flattery construction, its initial stability is incredible. So you basically put these implants in and you immediately see increased initial implant stability because of this greater coefficient of friction at that bone implant interface. So pretty exciting. Just when you look at the one new edition of adapters being the bio foam edition and you go, where did this adapters come from? What is adaptive is why is this suddenly hear what took place in the last 10 years? Well, if you look at the adaptive technology, it is Theobald E now, too, with the introduction of three D printing to go ahead and allow us to place the bio foam on a variety of different types of metal implants that are three D printed. And this followed the merger of 28 with right medical. This was a basically a technology that had been available through 20 a that used on their shoulder replacements and with the merger of tourney, and right now we could take this technology and merge it with our total ankles. They're always working there were already working well, but now can work better with this poor sauce bio foam in gross surface. So again, this is the adaptive technology that was made available because of the merger with tourney and the past experience with their total ankles that had this similar technology. So again, this is now based over 20 years of published experience. Onda again, a lot of different technologies A to play here and they're leveraging the whole three D printing process. But again, it's going very well. This is not just new because again taken from the experience of tortilla had and just merging it Now with the great opportunities of total ankle Arthur Plasticky on reconstructive surgeon, the right medical has. So let's apply. Adapt us now to the infinity, so infinity that you know in love. Now you add the adapters to it. So one of the benefits of adding all this three D printing Well, you're gonna get this integrated poor structures. You can deal with complex geometries. You can optimize the poor substrate coverage. Our pores pigs have still a solid inner core. But now you've got pours on the pigs themselves. It also has solid stretch that are built into the whole model block or the substrate which provide improved strength of the whole unit. So all these things are very important. When you look at the materials, it is still the COBOL uh, chrome type of unit. But now you have the titanium porous coating over the top. How is it different than the current infinity? So again, there's the current affinity, you know, on the left, and there's the new adapt is on the right. You see that we lengthen the poster preg on. Of course, all three pigs air now are now coated with the bio foam material. So again, our poster pig length is increased and the in gross surfaces has been added to all the previous smooth pegs, whereas we used to have a great blasted on growth surface for the old infinity. Now you have the three D printed in growth, not on growth in growth surface design. We also have a new Polly highly crosslink Polly. We'll talk about a few minutes. That's a big change to this adaptive, uh, infinity that was not available for and again, with the three D printing opportunities, we now can provide you model block metal components, which again will have greater bone in growth opportunities than the old forge plasma spray coated type of device we had in the past. As far as the new flat cut Taylor's, that's available infinity with adaptive. You'll find that you can place the holder the handle, so to say, for insertion of the tailor component could be placed from either side. I use that today. It was very helpful trying to avoid impingement on the medium. Leela's I was able goto lateral side and able get the inter planting a much easier. We've harmonized the stem diameters. It eliminates the need for the second in bone. Drilling for the central stem basically reduces steps of reduces. Uh, the time that goes into that, you'll see that we actually all three pigs, the same diameter, so you just drill them all the same. You don't have to go back and forth with a separate trial, and we included a shorter central stem, which not only eases the implant placement but also minimizes any risk of sub Taylor joint violation of people with Taylor Dome bone loss. And again, there's your mountain black design, which eliminates the need for back table assembly. This is all one unit. You pop it in, you have to read about pounding it on the back table on getting that ah larger central stem in place and then of course, what else has changed this adapters, if that's not enough. Well, then you have your Everlast highly cross linked polyethylene, something we've been looking to do for some time, but it's actually got great strength. But now it's blended with Vitamin E, which has been shown to lower the risk of oxygen oxidation will not impacting the cross linking process or its mechanical properties. So with this new Everlast type of highly cross linked polyethylene, we could improve where resistance up to 26% of what we saw in the past. So again, as you compare to our legacy polyethylene again great ability to handle forces. But now even better. So again, this stabilizer allows the material to be stable from oxidation without re melting the material and while preserving your mechanical properties. Which is so important for these Upali implants that we utilize for total Encarta. Classy. So, again, again, just another, um, laboratory study looking at again cumulative where, um, as far as the legacy polyethylene versus the new one, uh, the Everlast and you'll see that again, um, does very, very well in lessening where, as you increase cycles, so we feel that this will be another wonderful edition to the infinity with the adaptive technology already seen. So just a quick summary. Now where we are, this adaptive technology takes the successful infinity device. We've all been utilized last 10 years, and now you have a three D printed poorest metal component that allows for early stability but also born in growth as early as four weeks That increase initial stability. You see immediately when you put that implant in, uh, it's a single model block construction so reduces the possibly of any delamination. It reduces a lot of the just the time efforts that go into assembling the device in the back table. And then, in addition, they ever last how they crossed the polyethylene improves where resistance because of the infused vitamin E but again doesn't take away any of the mechanical properties. So all good and you can still use prophecy, which I do for every one of my cases. So prophecy navigation you all know about it improves accuracy. Many, many studies have been in the literature showing how it does indeed, uh, improve accuracy. Um, because you're bypassing the standard extra articular so called instrumentation. It saves time in the or and again, there's been over 23,000 total ankle procedures now that have been planned with the prophecy, perhaps navigation to date. Experience matters that does work, I find to be extremely helpful. So just lastly, I just share you with you. My my experience with the Infiniti, utilizing the adaptive technology over the last. I guess it's almost been 16, 17 months. So I did my first adaptive, uh, implant Infinity Implant. In March 12th of last year, I was the second of United States. A friend of mine in Chicago beat me to the Punch, but we did our first one here in Green Bay early March of last year. Since then, I've been planted 51 of these adaptive modifications of the infinity all the Madonna prophecy. As I said, I'm a big sham for guy. And so on. Li. Two of these were done with the flat cut Teyla's My first ever Last Polly was implanted just two months ago, July 15th, as's faras, my adaptive Siri's. To date. I've had no revisions, no failures that I know of, and I have had two people with delayed enter, uh, moon healing that fortunately eventually did hell with appropriate wound care. Again, there is just a picture of the Everlast probably going into place with an affinity with adaptive modifications made. My technique with this adaptive is exactly the same technique with the original infinity. I do make a couple of little variations that you might be interested in. For last many years, I've been using a small medial incision, as you see there on the top to perform a poster capsule, er, elevation, but also, and probably more importantly, to protect the nerve Askar bundle. I like to go ahead and put a retractor in the back. Some kind of elevator, Um, and you can actually go in under the poster tip. Do your poster of caps a lot of me. Then place a large metal instrument to then protect your nervous your bundle. When you do your bone cuts from the anterior aspect, I do a standard and your approach to my ankle joint itself. You'll see that in the bottom, right and again prophecy guides in place. But again, it is the same technique is an original infinity. Both Hodges and I have always preached that where you want to do good, healthy gutter debridement. Ah, good gutter decompression. Because of that, I always downsized my tailor component. So if I use a four to be, I'm gonna be using a three tailors because I do do a fairly healthy gutter debris mint on both the media lateral aspect. I do a gastric concession. About 30% of the patients that I do a infinity with adapt us on. I do this when I have still some tight range of motion difficulty, fully doors reflection with even the smallest Polly. So if I got the smallest, probably available, that fits that particular size and it's still a little tight I usually at a gas truck recession. So again, about 30% of my patients get get a gas truck recession. Perhaps, Hodgins. I can also maybe talk a little bit about B. M I and age, but these are things that we're looking at as well, but I'll show you very quickly a couple of cases. This is my first case with adaptive technology. In March 2019, 61 year old woman, she had an old ankle injury. She had, uh, some of Jason joint issues there as well. You see a little asked. You fight information around both the sub Taylor tend to recur joints, so I offered her the opportunity to do a total Encarta plastic thought her age and bone quality would be appropriate for infinity. And now I had the adaptive technology available with infinity. So we did our C T scan that confirmed the arthritis not only the ankle but the surrounding joints. I went ahead and sent my prophecy report. It returned. Says I should be using a size four tibia, a size three infinity Taylor's. They know me very well. This is what I typically will get from the engineers because they know I like to downsize my tailless. I do usually undersize again because that got hurt agreement. And also, I just believe in preserving bone. So if I can use a smaller tailors and preserve a little bit more Taylor bone, I certainly will do that as long as I have adequate coverage front to back and such. So here's the interrupted a picture of the new model block with the poorest coding of the bio foam and you'll see there we've been planted. Our device looks good and here she is 14 months post up doing very well sites. No pain as good range. Motion alignment remains very good. And so a very successful first case using this. This is my most recent case. I just did this this past week. 75 year old woman, old trauma. So you see, she's had the old tibial fracture. She's got a little bit of various. She's got bone on bone, but she also has sub contra assist, and you'll see the C T scan there. There is a void in the distal tibial, not just a sub contra assist. There is a large void in the distal tibia, so I basically got my C T scan. I sent it into the engineers. The engineers wrote back and said, I think maybe you should consider a nem bone tibial stem because of this central void in the distal tibia. Again, that's the advantage of heaven. C T scan of prophecy is you can look at these things and evaluate ahead of time, but I thought, No, I I think this is something I could still do with the infinity. With the adaptive technology, I think I can deal with that cystic change with this and again. Point of contention. Perhaps a little controversial, but I like to stay with the infinity. I used a larger size. I worked with engineers, usually larger stars make sure I was covering the entire the entire cortical rim of the distal tibia. I went ahead and drafted the distal tibia. I used the bone harvested from my reception's as well as the pro dense on. Then I use cement on one of the areas of the distal tibia where there remain some concern about, Ah, assistant void. So again, that's how I elected to do this. It went very well. There you see US post op early again. This has just been one week. We didn't see my graft material up in the distal tibia and also cement around the distal peg, particularly that medial side where the major cyst was located. So again, my most recent case, this is one of my most interesting cases, though just highlight one thing I want to just share with you all. This is a 59 year old woman. Bad trauma, multiple surgeries. She's got a Cal Canio Mel union. She's had a prior sub tater fusion. You can see there. She's lost pullers angle. She's bone on bone at the ankle joint level. We went ahead and got a CT scan. Noted that she had indeed Fuser Sub Taylor joint. We did a force copy injection the ankle joint, which did provide temporary relief of most of her pain. So we felt that her problem was indeed at the ankle joint level. Uh, CT scan was sent to the engineers for prophecy, evaluation and guidance. But you'll see there's the C T scan in and look at that. That left image and you'll see not only the male union, but look at the amount of bone that's in that sub fiber region with significant lateral wall impingement. We got the report back size to tibia size one Infinity. Um, everything looked pretty good, I thought. Okay, let's go for it. Um, we did Also, through the prophecy guidance, we noted that her hind foot was indeed mail align. She had a significant amount of lateral wall widening and displacement. But again, we thought that we had adequate, um, tailors to use to put the implant on, and we deal with the rest. We got in the operator Interestingly in the afternoon. I cannot. I was planning on a sham for cut, and I could not get the tailor cutting guide in despite multiple re cuts. So I finally said, Okay, we're gonna go to the flat cut tailless, did this free hand, and then use the flat Taylor's Monta block option. You'll see that there. There's what it looks like now. All one contained unit where you enjoy your holes all at once, which certainly saves a lot of times. So again, I bailed off in the sham for to this, uh, in the middle of the case because I just did not have enough room to get the sham for cutting guide into proper position. Everything worked out fine. The ankle the great There you see it lined up very, very well moves. Well, excellent stability. But I still had issues with the hind foot. Did a hind foot alignment view. I wish that a little bit better for you on the far left side, but it did show I still had a fair amount of bone underneath the fibula s. So I went ahead and did a medial displacement Cal Keano astronomy. You'll see that alignment view there, on the middle of the section in the middle. And then I used a muck 70 screw to actually fix my realigned hind foot then. But the thing I want to point out, though, is when I went back and re review my property report trying to figure out why this happened, I realized that the engineers warned me that they said, because of the amount of height that she had lost previously, they were going to plan for less reception of bone. And when you under resect bone, it is difficult to get that chance for cutting guy in proper position. So, again, something I've learned from this case and I might recommend to you that if you do see the report, come back and said, You've lost haIf we're gonna plan on Under respecting Bone. You might want to just bail out immediately or plan ahead of time to do the flat, cut a list, ran and try the shampoo cut itself. So in summary, this has been exciting for me. I've done a lot of these infinities. Now, with adaptive technology, it's working great many exciting additions to an already successful original infinity Onda again. I hope this has been of interest to you. And I will now share my, uh, screen with Hodges, Who could talk about his experience. Hodges. All you. Thanks. Thanks, Bob. I'm gonna get you toe unshared so I can I can put my slides up so that I can control. You know, you've known me long enough to know that needed control. Um, you know, it is It is so good to be on the same program with you. I've missed you. You're going up to Wisconsin. I'm glad. A couple of things that you still say a lot of y'all's. And, uh so you haven't been completely Midwestern ized. You also haven't gained any weight. So I'm feeling good about your diet, or I suspect that knowing you, it's mostly, uh, brown and khaki that you're eating. Um, all right, here's Here's a question before I get started. So if the's air custom printed, how do you bail out of a champ recut to a flat top Taylor's? Does it come with both? Um, so, Bob do do you want to answer that? I'm sorry. How doe I bail out. So they're the implants are not custom printed. The only thing that's custom printed is the prophecy guides. What the implants are is the sizes are printed. But because of three D printing, we're able to make everything in mono block, including Thean Growth surface, which then which then changes the game because we now have something that's not centered on. It's not sprayed on it z one system. So the number three tailors of the number two tailors that you use there was the number two mono block tailors, and it's very easy to switch back and forth between that and you you showed that quite nicely. Comments exactly. No, no, you're absolutely right. It is. It's it's It's very interchangeable when you're getting the same technology, regardless of which implant you choose. Okay, Um, So So Bob and I were partners for 25 years, and I can't imagine that we're not gonna be partners forever. Sometimes when we're at the pearly gates, Bob, uh, Jesus, God's going to say, all right, you go over there with Anderson because you're supposed to be together. But I was I was so impressed with Chris is, um, introduction of you and and really, you've always been an overachiever and clearly anyone who's done over over 50 total ankles with the sports practicing Green Bay is an overachiever. And and you know, I didn't realize how much an overachiever you were until I went to visit Ole Miss and and found out that in 78 79 there were five inductees into the Hall of Fame. And this is not the Nerd Hall of Fame. This is a really hall of Fame Archie Manning and Eli Manning. Or in that, and, uh and you know what? You still have great hair. And, uh so I love being a part of of everything you're doing. And it's awesome to be back on the podium with you. I feel feel like like we're back on it. Um, So my my role here is to try to talk about our real experience in Charlotte with infinity with adaptive technology. So how's it going to date in the United States? This was three days ago, so it may have changed. We have almost 500 planet, and this is an implant that really the full launch is not happening till this month. So all the sets really went out this week. Um, it has not gotten health Canada yet, So if there any Canadians on But it's coming. And at Ortho Carolina as of a Ziv two months ago, we had 20 implanted. Now it's been a fume, or they're all done with prophecy. And five was done with a flat cut because one of our partners, um, loves, loves the flat cut does them on all of those and and it's kind of interesting. About 50% of the United States anyway, does that just goes with flat cut, gives them a little more room, and they feel like it's something that will speed that up. Um, so the technique tempts Bob has already talked about about that, Really no appreciable change in the technique on the tibia. There's no change in the tibial broaching steps. This is a question. I get a lot, Um, you have to clear the longer peg, but it really is not a big deal to do that. It doesn't mess up the tail us, and you impact with it the the impact or parallel to the pegs. Sometimes you have to finish with the straight tibial trey impactor, which is in the set and that will finish and get it get it kills because there's no doubt that the surfaces more tacky than it normally waas. But when you put it in, the stability is is definitive in all types of bone, as Bob pointed out, and so it really has made a difference on the Taylors. There's no change. You don't have toe have to break the tail is to get it seated. It really seats quite nicely. So this is our patient Alfa in Charlotte. 72 year old history of an ankle fracture 35 years before a classic, um, classic post traumatic severe disabling ankle pain with some Val Ghous and the collapse. Um, here is the C T scan and you can see that that the hardware is gonna be a problem. But again, fairly straightforward as these go, you can see had to take the tibial hardware out. This is the first post op visit and this is 18 months post op with full activity and what I love to see in these is you can see the on growth, the end growth, not the on growth. You really can see it. And we used to see this with by phone still do with by phone. And we know that the end growth has happened and the initial stability as well. Azaz What we're seeing almost at two years is really quite impressive. Here's a 49 year old who had multiple surgeries and the last one was the sub contra plasticky. Not unusual that we're seeing some of these that we're having to go back and do something west. You can see the sub contra plasticky material on the medial side of the tailors, and this is one that we on purpose did a flat cut using the the old flat cut. This is at first post op visit and this is at nine months and you can see the end. Growth on the tibia is dramatic, and, uh and that's kind of what we've been seeing. Um, this is Aaron, mate, who did the first block. Taylor's in the United States, and and this patient is now about about six months out. Um, I would tell you, though, that when you're talking about total ankles, that implant choices, a cautionary tale and as as we've gone through this process and Bob and I have been part of a very active ankle. Um, designed group. We really felt like all of these implants, um, fit into the continuum of care that the complex patients with ankle arthritis need prophecy. I think it's essential for so many things. The infinity with the shampoo cut the infinity with the flat cut or the block tailors in bone. And with Bob and I have been doing in bone for 10 years, plus in bow to anyway in bone for for close to 14 years and then envision which is really the first and Onley truly modular um, revision system that is present. And in my practice, I use every one of these options and I'm old what is needed to the patient by using the implant that is needed. So we know the Infinity story is articulating surface correct access, all those things. Our goal was precision with reproduce ability, stable fixation, longevity. We wanted, like the total knee, and we wanted to use it for some complex deformities. But our goal was never to eliminate in Bo. In addition, we we really believe and continue to believe that it well executed two piece total ankle was better than a three piece design. We have no backside where we get great Corona stability with the exaggerated satchel sulcus. And we're not seeing there early osteo license that some of the three parts saw. So we thought there were theoretical advantages of of resurfacing, and we also felt that there was increased salvage ability. Um, in some of these, both in the tibia and the tailors. Um, So the new system was going to be a compliment to end bone, not to replace in bone. So all these goals were important, but we needed this system to be in bone compatible. And so, with experience, we're defining the ankles that are best for infinity and for, and bone is a primary. Both systems, in my opinion, are essential toe handle the challenges of this difficult patient population. Infinity is ideal for for a maybe even the majority of the end stage ankle arthritis challenges, as Bob has shown. But I would recommend Don't give up your in bone, and I'll get Bob's comments on that when we move forward with this. Um and these are the lessons learned. This is a patient, actually, Bob, I think it was one that that you and I shared. 72 year old gave a very but various degenerative ankle. He's a tall, big guy and he's modeling neuropathic, right? And I really do believe there is mildly neuropathic. It's not like being kind of pregnant. We see these patients that have a little neuropathy but severe pain that mirrors what we normally know in these patients. So we did the foot first, fixed the various hell and in eight months later did an uncomplicated prophecy infinity at the first post op visit. Everything is looking good at five months post up, Hey collapsed and developed a medium al fracture. We ended up doing a two part staged revision and hey, had as a as an envision in the tibia and then in bone in the tail is he's now 3.5 years out and doing fine, and this is one of those patients where I go. What did we miss? And I think we missed a few things, and so ultimately in my practice now with with a high level of deformity in my practice, I'm doing about 100 a year, and I'm doing half in bone in half infinity. Eso My infinity patients are young, they're low to moderate deformity, they're less stiff and they have no neuropathy. And when I'm saying no neuropathy, I mean that infinite. Who was to end bone flat cut? Taylor's is patients that have a flat tail us already that air stiffer like Bob showed. I mean, if you change, um, the the height you may have to go to a flat top. Taylor's complex deformities of the tibia and hardware challenges in in bone. I use it older, softer patients. I use it in my in my obese patients and in particular in the mildly neuropathic patients with bigger deformity stiffness also who have severe high foot fusions. And I use them for some revisions envisioned for primaries. I used the tibia for primary with severe bone loss and poor bone quality and the tail us for primary that has poor bone on DSO. Sometimes I use it for two stagers that I do a hind foot fusion First eso prophecy infinity young low deformity, lest if no hint of neuropathy so set 63 year old young ish anyone is close to my age is getting really young post traumatic. Andi used an infinity with adaptive technology and prophecy. First post op. And here it is that one year doing great. No evidence of subsidence, loosening and pain free Infinity with flat top cocktail us. Which ones do we do? Those this one is various, is stiff and has has significant disabling ankle pain. With no neuropathy on, do you can see how the tailless is flat top and so doing a a champ er Taylor's You might notch the tip the tailor neck. So here's the prophecy and the prophecy works great with the flat cut tail us. And here's what it looks like in Bonn. Tell us more Room did notch the tail us. I could be super aggressive with the gutters that had a little more room, and the deformity is corrected. Some people say that the speeds up the process, Um, for me, doing a flat Taylor's versus a sham for Taylor's Onley Onley adds about five minutes. Um, here's history of recurrent ankle sprains in a 62 year old you can see that's post here. Subluxation is not that big a deal, though Most of these folks require either a gas track or a TL super stiff, and this is one we went with an infinity tibia and a flat tail. Us. So here's him at seven months post up, and you can see how the tibia is. Aziz in growth beautifully and in the deformity pre op has gone away with excellent gutter debris month. What about complex to form? A. Here's a 69 year old history of open tib fib treated with Rush Rod in the fibula. Five years of progressive fame Is this pain? Can we do this in one? Operation Prophecy is extremely helpful with that's are sent in a prophecy report. And I said, I want to put this in on the mechanical axis and they said, Sure, you can do that. And this is what the Prophecy report showed, and in fact, it was not that hard to do. Compared to plan worked out beautifully, and she is now four years out not living in our area, so I don't have any standing films. Um, what about in bone modeling? Neuropathic older software patients with big deformity 59 year old with a significant various has already failed a reconstruction that includes a a Cal Caneel last iata me and a lateral ligament reconstruction and you can see here were able to fix it in a single stage. And did the door selection ost iata me of the of the first? What about envision as a primary? Um, I use it for in the tibia for bone loss and the tailors for poor bone. I also am trending to use envision in patients that I do these big first reconstructions to get the foot out of alga. So I've done a double with the M, D, C O and a. Lapidus. I've got to Mary's line great, these patients. I'm cutting a little lower and doing and envision Taylor's because I think it protects me from a B N. It was 59 year old six years status supposed to try Mao. C T scans show severe tibial bone loss two years post using envision tibia protected the medial mouth because that was that was super concerning on the cat scan flat, flat in bone. Taylor's here on the tail is 59 year old history of our A. You can see how bad the tailor bone is. This is one that I'll have to go a little lower on the tailors and use an infinity tail and envision tailors. And you could see how nicely the envision Taylor's does with excellent fixation in the in the more distal part of the of the tailor, neck and body. So my conclusion is infinity shows excellent early results. It is my belief that adapt this technology will expand on this and will be a massive game changer. In my opinion, um, comparable or better than previous mobile mobile bearing designs that I've seen both in my experience as well is in the revisions and I'm doing, um, In my opinion, uh, all of this technology is encouraging for ongoing use and further study s So far, early feedback has been great. A zay said over 475 cases. Scott Ellis says Infinity even better than before. Dr. Vora says this robust prosthetic bone interface in growth results and improve initial and long term implants stability. John Lewis and Louisville says the initial component fixation stability followed by predictable, bony and growth into the processes is a game changer. Eso improve long term fixation and cruz initial stability and improved where resistance um, Alright, Bob, any comments. No, it was great, Hodgins. I agree completely that you don't want to use infinity. Even with the adaptive technology for all all comers, you really have to think about all the other variables. And I completely agree with you if I got somebody with poor bone quality or really bad, rigid various rebellious deformity or, uh, somebody who just, you know, revision situation, I'll go to the Imbo, or I'll go to the inn Bone within envisioned tailless. And and so I think that you really do have toe understand all the nuances and and not just get stuck in the thought process that everybody's gonna get infinity type device. I I am intrigued by what is mild neuropathy. I do obtain a nerve conduction study on patients with diabetes who I'm concerned about. Some Paris Tasia issues some loss of sensation, and I have not been doing total ankles and everybody with a poly sensory. Um um you know, Technorati pithy with a, um, you know, you know, basically a concern Where they having up there? I don't know. What you defined is mild. I basically if I find if if they've got neuropathy, um, you know a symmetric, you know, sensory motor neuropathy on that neurologic study, I typically will not offer them a total ankle. On the other hand, I just had a guy who I because of that I did an ankle fusion. He went on to non union. So you know, who knows what's better, But I'm interested. What you think about my own neuropathy. Also, the other thing is, I have not yet found were b m. I, um, is a threshold I have been doing up here. There are a lot of large individuals and higher bm eyes, and I have not found that to be a deterrent to doing, uh, even the infinity. Maybe I should be doing more in bones and or these people same with age. I did an 82 year old. I did it in bone last week. On the other hand, I've got 75 year olds. I might still do infinity. So those three things real quickly, what is mild neuropathy? Do you have a B m I threshold? And what about age? So So I I do know conduction studies also, but Bobby would be so proud of. May I walk around with monofilament testers in my lab coat, and you can order them on Amazon and you could get a whole bag of them for about five bucks. And, uh and so So I I do monofilament testing. And if the monofilament testing is his negative meaning, you know what a negative is? 5.1 Like we talked for so long in the complete foot care course. Um, then those air patients that, in my opinion, have have mild neuropathy but still have protective sensation. And those patients, I will do an ankle replacement. Um, if if they If they fail that I'm doing a fusion and I'm not, hasn't it Thio Thio Taylor Falcon Eel fusion in those patients? Because a Z, you know, those things can fall. Follow, um apart quickly. The second piece in older patients is find that that in bone even has better initial stability. Now, I may make the shift back as I get more and more confidence with my adaptive patients. But I But I am still using If I have someone that I know their bones gonna be a little soft, I just go straight to end bone and it it for me that works. I know I could move forward. I can walk him very early. And I think the morbidity on these folks is less. The other piece, which, which may or may not mean anything, is within bone. I could do a smaller incision because the cut guard is up top. Um, and so in those patients, I I'm still 10 trending towards in bone. May may change. And, uh, seeing your patients and what you've done with with infinity, I think is, um is great. And and that's that's the way it iss. All right, I just got got no, not 5.15 point 07 Bobby should have corrected me. Yeah, And what about B m I? So the ones that I immediately go to end bone on are the ones that have mild neuropathy. And so if they've got some mild neuropathy and they're big, I go to end bone on 100% of those. So So? But if they're if they're just obese with not a not a bunch of deformity, I still would do infinity on those folks. And I really think adapters has changed my because they really they grow in quickly. I do protect all of my total ankles in a boot till about seven or eight weeks. And I think that allows foreign growth. It allows for nice stability. And it also calm down the soft tissues. You know, Bob, you you're the one who taught me how how much casting and booty can kind of calm the soft tissues down. And I think that they feel better when they get to physical therapy at 68 week Mark. Yeah, I was I was gonna say, Tu Hijo just talking briefly about post op management because so many people want to know what we're doing Post op these days is pretty much I assess the wounds of two weeks, and for the most part, I'll put people back into cast for another two weeks, keep them down, wait for until four. And then I let him wait for in a boot for four weeks, then pretty much out of the boot by eight weeks, um, into a shoe and start physical therapy. So, I mean, that's a very general look at it, but I don't know what your plan is now, but generally speaking, I'm walking at four weeks and into shoe by eight. That's exactly where I am, exactly where I am. And I just find every time I try to get him out of the boot earlier, I think they struggle with swelling. And, uh, the nice thing is, I could get him in a compression, uh, sock while they're in the boots. Um, so So, um, yeah, I'm exactly the same. And I don't mind. I don't mind slowing them down a little bit, but it makes a big difference in an 80 year old to be able to put weight on it early. I mean, it does and, uh, they're patient with the wounds. But but putting putting an 80 year old on crutches is something I try not to do. And I know you love doing doing extra. I'll fix it or frame so much. But I could see you just sticking them in an external fix it a friend s o the only that that was the only comment was gonna make I meant to do in this life form was talking about my infinity and true for in bone and other total ankles. Uh, envision is how often I actually add a dorsal flexion. Asked anatomy of the first metatarsal when I'm correct in the various deformity, and I just think that everybody should be ready for that. Always have that on the back of your mind. If you're correcting various deformity, whether you're doing it with the infinity or in bone that always be prepared to add that at the end of the case, I had good example of that today. So again I would say that the vast majority of people I'm correct in the various deformity of the ankle I am adding the door selection. Nasty out amount. If that's been your experience as well, Absolutely. And I'm I'm fixing them a little different just because I want to get him, Get him Walk. And I used to use a compression staple. Now either use a nightingale staple or do an oblique Osti Autumn and used to screw. I'm doing some M. I s dorsal flexion, Austin armies playing around with that, and, uh, that that speeds up the healing process for sure. Okay, Um, Chris, we're right at seven. We said we had a hard stop. Do you have a few final words and then we'll we'll call it an evening. Yeah, definitely. So, Bob Hodges, Thanks so much for taking the time this evening. I mean, just the discussion around patient selection around the new technology around your algorithms for care was awesome. And just thanks to everyone else else that's out there. I really appreciate you joining us tonight. We hope that you found this webinar beneficial. And if you're as excited about this new technology as we are, um so if you'd like to learn a little bit more about infinity with adaptive, please reach out to your local right medical sales team or feel free to visit us a right dot com. We'll also have this posted up on a virtual learning center, which is right med ed dot com. So feel free to join their. And then throughout the course of the end of the year, we're gonna have a bunch of additional webinars and a variety of innovative topics and right medical. So feel free toe to join one of those If one of those peaks your interest. So thanks again and have a great evening. Thanks, everyone