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Foot & Ankle International
FAI April 2026 Podcast: 1,121 Salto Talaris Total Ankle Arthroplasties by a Single Surgeon: Mid-Term Survivorship, Complications, and Patient-Reported Outcomes
00:26:48
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- [00:04]
A
This is Mark Easley and I have the distinct honor of talking to Dr. Chris Coetzee, the senior author of April's lead paper in Foot and Ankle International. The paper is titled 1121Salto Telaris Total Ankle Arthroplasties by a Single Surgeon, Midterm Survivorship Complications and Patient Reported Outcomes. Chris Katzia is recently retired from clinical practice. He is past president of the American Orthopedic Foot and Ankle Society and current North American Federation Council Member of the International Federation of Foot and Ankle Societies. He continues to serve as a team physician for the Minnesota Vikings. Chris is originally from South Africa and completed fellowship training at the University of Washington Harborview Program. After practicing in Canada at the University of Minnesota, he maintained a busy clinical practice at Twin City Orthopedics in Minneapolis. Chris has been an international thought leader and household name in foot and ankle surgery with a particular interest in the management of ankle arthritis, especially total ankle replacement. Dr. Saltzman and I selected this article to highlight the single surgeon large cohort midterm follow up of surgically managed patients with a fixed bearing Salto Telaris Total Ankle System. Welcome to the program, Chris.
- [01:13]
B
Thank you, Chris.
- [01:14]
A
As senior author, would you please give the listeners a brief summary of your paper and its major findings?
- [01:20]
B
Thanks, Mark. I'll make it short because obviously the readers still have to read the paper, but this study obviously includes a large number of total ankle replacements and we used multiple validated PROMIS scores that confirmed statistical improvement in functional and pain outcomes. Unfortunately, as expected with this procedure, it is not without complications. Our total complications were about 21%. Most of them were not serious, but over the course of the study, 12% needed a reoperation. And unfortunately as well, we were not spared from the most dreaded complication of total ankle replacements. Two ended up with a below knee amputation. But the good news is that our outcomes were similar to previously ported studies where the survival rate at 5.5 years was 94.6%.
- [02:21]
A
That's great. Yeah. Thanks for giving us an overview. Chris, you participated in a multi center study of the Salto Telaris total ankle system with Results published in 2023, also in foot and Ankle International. Since that multicenter study was published, what more did you learn from your single surgeon analysis of the same procedure?
- [02:41]
B
Again, as expected, there were no major new revelations. The big issue is with the multicenter study, one of the limiting factors is that every center must use the same outcome score. So at the time we were using different scores. So with this study we could present all the outcome scores that we collected. Standard practice at Twin Cities Orthopaedics, which I think is more complete. And the only slight difference is our survival rate was about a half percent lower than the multi center study.
- [03:16]
A
Got it. Okay. So Chris, arguably you successfully ran one of the busiest clinical foot and ankle practices in the US and probably the world. Would you please share with our listeners, especially those surgeons who wish to be productive in research, how you found time to also be so impactful in publishing your outcomes.
- [03:36]
B
That is somewhat multifactorial, but I am lucky to be in a private practice that is dedicated to producing high quality research for listeners that are familiar with hip and knee literature. Two of the most prolific researchers and publishers in the country is Chris Larson and Rob Leprade and both of them are my partners at Twin Cities Orthopedics. And also because of our desire really to publish the Promise course are built into our EMR system. We which makes it much easier then to look back either retrospectively or you can do it prospectively. Each subspecialty as well could build their own platform to make the scores applicable to the procedures or the pathology that you treat, which makes it a much easier procedure than to do research. And then we also have a great biomechanics lab on our campus which is somewhat unusual for a private practice. And as far as I know, we either had three or four full time research staff and there's always a multitude of medical students and fellows working on research projects. That is the advantage also of building the outcome scores into the EMR instead of like in the old days where people had to sit in the waiting room and fill out the forms. So basically, in short, I think there has to be a desire to do research. And then after that with EMR it just became much easier to do so because PROMIS course can be built into your EMR system.
- [05:21]
A
That's great. That's good advice. Especially as you move into more modern ways of doing our conducting our research. We serve struggle at our institution some, but those surgeons that have built it into the EMR have an advantage and probably produce much better research. So that's good advice. Thanks. To take my previous question one step further, not only were you one of the busiest, but also one of the best foot and ankle surgeons in the world. So no doubt word got out and patients traveled from all over the country and even internationally for you to perform their total ankle replacement. How were you able to maintain such consistent and careful follow up for over 1,000 patients?
- [05:58]
B
You know, in the end it came down to a lot of prodding and begging from whoever was working on that study, but also with a very specific practice profile like you have as well. When patients come to you, they need to basically sign up or sign in to follow the rules of engagement. And one of the rules of engagement for me was that you have to commit to be part of the studies that we do. And it was interesting for me over the years, people, after a while, become somewhat invested in it, and they want to know what the outcomes are, and they want to know if the procedure that they have is actually as good as what I try to convey to them. It will be. And then, as I mentioned before, the outcome scores that's built into the system makes it much easier. And for me, that's still. It's been the same throughout my career. Total ankle replacements need to come back once a year. And luckily enough, by far, the majority of the patients did that.
- [07:03]
A
Yeah, we have some of the same at our institution. And it is always comforting to hear patients say they want to be engaged, they want to help others, and they see the value in being there even when their ankle seems to be performing well and they don't feel the visit absolutely has to be done every year, but they seem to come back. So that's good, good information. Thanks. I'm going to diverge a little bit from the paper. You are originally from South Africa, where temperatures can get cold, but for most of the year at least, I think the climate is rather desirable. So how were you able to survive practicing in cold, cold, cold Canada and Minnesota for most of your orthopedic career? I mean, I'm sure the summers are nice, but they can't be more than a few weeks out of the year, right?
- [07:46]
B
Correct. I think initially it was supposed to be an adventure for a year or two to see how the weird people in north can withstand those terrible cold winters. But then after a while, it's like anything. You kind of get used to it. It's for sure. Not that I'm loving -10 weather, but it is what it is. And we just take a few warm vacations during the winter and that somehow gets you through until it's April or May, and then life is great.
- [08:17]
A
All right, well, thanks. Let's get back to the paper. The total ankle literature suggests that gutter impingement is one of the most common reasons for reoperation. In your study of over 1,000 total ankle replacements, you and your co authors reported only two cases of impingement. Moreover, at the index procedure, you Reported medial and lateral gutter debridement in only five angles. What is your secret to limiting this risk factor?
- [08:43]
B
You know, I don't think there's any secret. And I probably have to credit our friend Steve Haddad for this. A long time ago. He taught me that. And very aggressive cutter debridement during the primary total replacement is not an additional procedure. It is part of the procedure. And that's basically how I approached that. So that was just part of the procedure. I didn't even report it as an additional procedure. The cases where I could not do an adequate aggressive gutter debridement through the anterior incision and where I had to make a separate incision, then it becomes an additional procedure because there is a separate incision.
- [09:27]
A
Understood. Thank you. In addition to being a busy surgeon, you are also particularly efficient in your surgery. Implanting a total ankle replacement and achieving the great results report in this study is no simple task. In talking with you over the years, I know that you and your team routinely and safely performed multiple ankle replacements in a single day. Would you please share with the listeners your tips and tricks to optimally implant a total ankle while also being efficient in maximizing your OR time?
- [09:58]
B
Yeah, that's interesting. I think it's multifactorial. I always spent the evening before going through every case and make sure I know exactly what the plan is and what the potential byways can be that I need to be aware of. And I still believe, even as a very experienced surgeon, that it is most critical not to walk into the operating room and be surprised with what you find on the table. Furthermore, I use exactly the same two teams for more than 10 years in the OR. So it's almost like having dinner with your own family. Everybody knows what's going on and there are no surprises or unknowns when we go through the cases. And I was taught many years ago by my mentor, Dr. Hansen in Seattle, that efficiency does not necessarily equal fast, and fast that does not necessarily equal efficient. There are no shortcuts with total ankle replacements. I think you still have to do every step correctly. It is ever true that experience makes a difference after a few hundred cases and I don't have to think about what the next step should be. So it's a combination of have a very efficient or and try to be efficient in movement during the procedure.
- [11:24]
A
Great. Well, I'm sure that'll be helpful. And having a good team. I agree with that. That's terrific. But thanks for sharing that you and your co authors reported on that the Two most common ancillary procedures to the total ankles were tendo Achilles lengthening in just over a third of the cases and lateral ankle ligament repair in just over 1/4 of the cases. Would you please share with the listeners your criteria for adding these procedures specifically in your hands on the OR table? What lack of dorsiflexion prompts you to lengthen the Achilles tendon? And what amount of lateral opening with various stress prompts you to add a lateral ligament repair? And to expand on my previous question, as a busy surgeon with multiple surgeries in a day, were there times that you implant the ankle and think, well, I should add the ancillary procedure, but I need to keep moving knowing that you always do the right thing, how do you manage this dilemma common to all surgeons?
- [12:24]
B
Yeah, first about the dorsiflexion. That was always intriguing to me. But Roger Mann said multiple times off the podium that he almost never or never did an Achilles lengthening and in his experience everybody would regain adequate dorsiflexion early on. That was unfortunately not my experience. And we quickly saw that if people don't have at least 5 degrees dorsiflexion, it makes it difficult to go up and down stairs. And outcome scores were just not that great or satisfaction scores were just not that great. And for me now, if I cannot easily get 5 degrees of dorsiflexion with the knee extended on the table, I would do an Achilles lengthening. Sometimes if I believe it's strictly the gastroc, then I would do a gastroc lengthening. But in my hands by far, the majority get Achilles lengthenings. And whether it's good or bad, I believe that increased dorsiflexion actually protects your ankle replacement because you don't get that constant anterior impingement force on the joint. The downside of it is you probably create some weakness. But unlike in the sports case, I think that little bit of weakness again protects the ankle for better or worse. And I did not find that. Patients after a while really complain about the lack of strength, but they appreciate the mobility. Then as far as lateral instability, again, I always compare it to the tires on my car. If your wheel balance is off, you will wear out your tires uneven. And we know that's the same in any joint as well. So if I'm done with the ankle replacement and I feel there's an objective, so question is, what is objective? I usually feel more than 10 degrees difference in with an inversion strength or gapping on the lateral side, then I will add a braustrom. The braustrom for me is one of those powerful, somewhat benign additional procedures. So I really have a low threshold to do that if I feel it's needed. And I don't think I've ever regretted doing a braustrom, but I know there were times where I regretted not to do it. So it became just more part of the routine if I feel I need it. And then the question about it's time to move on, you know, I can with reasonable confidence say that I've never not did an axillary procedure because I felt I needed to move on. I think if you want to be a good surgeon and honest surgeon, you just have to do it. And if it means that you have to cancel some of your cases, that's what you do. I would much rather tell the next patient I had to spend an extra half an hour or an hour to make sure that the most important patient, the one on the table, that got the correct procedure. And I want you to be the most important patient when you're on the table. So therefore, we need to postpone your case. And people are somewhat unhappy immediately, but they always appreciate that after the fact when they think, think about it.
- [15:36]
A
That is a great answer and great advice. Thank you. I'm going to diverge a little bit from the paper again. You are familiar with being a surgeon in South Africa, Canada and the U.S. from your personal experience as an orthopedic foot and ankle specialist, what are the salient differences?
- [15:53]
B
It's interesting. I trained in South Africa, as you know, but I never practiced there. I left the day after my residency. So I really cannot tell you about orthopedic practice in South Africa. But the main difference between Canada and the US is the fact that the Canadian system is substantially slower. And at the time I was young, right out of residency, and it really bothered me that I had to be done by 3 o' clock in the afternoon. In hindsight, I would love that system. Now, if I'm basically told at three o' clock you're done, you go home, you go play golf or tennis or whatever you do. While, as you know, in the States, especially in private practice, if I really want to, I can DO surgery until 8 o' clock in the evening, because for better or worse, it's a fee for service system and the system makes money if the surgeons work. Other than that, if you think about the procedures itself and the equipment, there's really no different. I used exactly the same surgical equipment than what I do here. So the quality is great, it's just at a much nicer, slower pace in Canada.
- [17:07]
A
Got it, thanks. And back to the paper. You and your co authors studied implant survivorship and you define this in your methods section. For the benefit of the listeners, would you please review your interpretation of the terms reoperation and revision in looking at many investigations, meta analyses and registries? I don't think that this distinction is always well defined. Do you believe that a reoperation constitutes a failure in Kaplan Meier survivorship analysis or if the metal components are retained then it should not be deemed a failure?
- [17:43]
B
Yeah, that's a good question. As you know, the Kaplan Meier survival curve non parametric graphs used to estimate the probability of an event, in this case the failure of the total anchor replacement. Again, I might be wrong, but I believe any operation that includes revising any part of the component should be deemed a failure and therefore affecting the KM analysis. But if you look at the specific reoperations, almost half of them were done for debridement of heterotopic ossifications. And again, I might be wrong, but I don't believe that heterotopic bone will affect the longevity of the ankle. Sixteen of our cases were done for conditions not even associated with the ankle replacement, but we obviously reported it because it was other operations. The only operations or reoperations where you don't remove or replace the components that concern me a little bit and might affect the KM curve. Benign with osteolytic cysts because we all know if you get big cysts, I think it's basically indication that your ankle is starting to fail because of poly. Those are the only ones that, like I say, make me nervous that we might have to report that it will affect the KM curves.
- [19:10]
A
Great. Thanks Chris. In your earlier total Ankle experience, you used implants other than the Salta Telaris and were on the design team for different total ankle systems over the years. With many new implants and new generations of implants introduced to the total ankle market, you had the opportunity to use other systems and did so in some capacity and in 2017 even published an article comparing three different total ankle implants. However, you have rather consistently used the Salto Telaris for your patients. Your results speak for themselves. But what are the reasons that you have stayed with the Salto Telaris, an implant that has undergone few if any changes since you started using it? I suspect there's more to it than simply that you can't teach an old dog new tricks or if it ain't broke don't fix it.
- [19:56]
B
Yeah, first of all, just for the record, I was not a design surgeon for the Saltu Tolaris, so I just became a frequent user. So it was not that part that made me continue with the Sulto. But make no mistake, I would love to make a few changes to the Saltu because I think it needs changes, but I was never able to convince the company to do so, unfortunately. Other than that, it is really a confidence level with the implant and my philosophy was always to give any new device time to create a track record and then see if I need to change. Which basically to your point means in my hands, if it ain't broke, don't fix it. And I continue to find the salted Alaris easy reproducible and I get good results with it. So there's really no need for me to change to something with a shorter track record.
- [20:56]
A
Understood? Yeah, it's hard to argue with your results and really, it's amazing work you've done to publish this large series. One more question. I posed this question to Lu Shone when he joined me for a 2025 FAI podcast on his outcomes with the trabecular Metal Lateral Approach Total Ankle in your core article over 20 years ago, you featured the concept of radiographic assessment of ankle range of MOT using weight bearing dorsiflexion and plantar flexion lateral radiographs. Your emphasis was on isolating tibiotalar range of motion from tibiopedal motion, since the pedal component may compensate for a lack of tibiotalar motion. In the current study, you report obtaining maximum lateral dorsiflexion plantar flexion radiographic views, but I did not see where you reported obtaining these views preoperatively. Range of motion analysis may be built into some of the outcome measures applied in this study, but I also did not see an emphasis on range of motion in your investigation. For the benefits of the listeners who wish to optimally study their total ankle outcomes. Do you continue to emphasize these lateral dorsiflexion plantar flexion radiographic measures to determine objective range of motion, or is a less defined tibiopedal motion evaluation satisfactory in reporting total ankle outcomes?
- [22:10]
B
I cannot recall exactly why we did not emphasize the range of motion in the paper, and maybe it was because the focus of this paper was more the patient reported functional outcomes, but I still absolutely emphasize the lateral maximum plantar and dorsiflexion X rays to determine the objective range of motion, and that's just part of our protocol. We obviously see Every patient before surgery and at that visit that do five views and that includes maximum plantar and then most of the ankles. I also do long leg standing X ray because I want to see if there's any varus or valgus component not in the ankle itself, but around the knee or around the hip. Because just realistically, if you just measure maximum plantar and dorsiflexion without separating your tibial talar joint from your foot, it is not an accurate representation of the true range of motion of the ankle.
- [23:14]
A
That's really good. And actually, at our institution we followed your advice and read your work carefully and we do exactly the same. So thanks for sharing that. I think that's important for researchers. One more time to diverge from the paper. You've been in the United States now for decades and have served as a team physician for the Minnesota Vikings American professional football team. Are you still partial to rugby and the South African Springboks or have you converted to American football?
- [23:41]
B
Well, I obviously love American football, but I still follow the Springbok rugby team as well as the Proteus cricket team on a regular basis. And you know, I think it's just in my genes, you cannot change that.
- [23:55]
A
Yeah, that's what I figured. Yeah. So, Chris, using a multivariable model, you and your co authors carefully studied covariates that potentially contributed to adverse events. You identified only diabetes as having an independent association with increased hazard of the event. And considering total ankle arthroplasty in diabetic patients, what were your inclusion and exclusion criteria and requirements for surgical optimization?
- [24:22]
B
I do not do ankle replacements for insulin dependent diabetics. And that might be a little bit controversial, but it's like anything. In 2000 when I was still at the university, I did diabetic ankle replacement that two years later went on to a charcoal joint. And you get one really bad experience like that and then you don't do it anymore. So that for me is unfortunately still a hard no. But I still do. And I will probably continue to advocate doing ankle replacements for non insulin dependent diabetics if their diabetes is well controlled. And I obviously don't manage the diabetes, but I will coordinate with the patient's primary care provider about management of their diabetes. And important for me is the A1C had to be or has to be less than 7% for me to proceed with an ankle replacement. But then also if there's objective peripheral neuropathy or vascular compromise, that would be for me an exclusion as well. Even in a non insulin dependent diabetic Great advice.
- [25:36]
A
Yeah, thank you and thanks for sharing that, Chris. This is excellent work. As our podcast comes to its conclusion, is there anything else you would like to share with the listener?
- [25:46]
B
Well, thanks for listening and my advice always for young researchers is never hide your complications. That is part of research and that's the only way that we can learn from each other if we know what the complications are.
- [26:01]
A
Yeah, that's great advice. I was fascinated by your article because often a picture is worth a thousand words and you have over a thousand ankles. Really great results and there's not one X ray of your perfect results. You went right to including the complications, which is being very comprehensive. So greatly appreciate it. I would like to thank Dr. Katsuya for sharing with us his insights on his and his co authors FAI publication 1121 Salto Telaris total ankle arthroplasties by a single surgeon, midterm survivorship complications and patient reported outcomes. And I would like to thank everyone for participating in this month's FAI podcast. I am Mark Easley. I look forward to next month's FAI Podcast.