A (3:44)

Great. Well, thanks for the overview. That's quite impressive. Just a little historical perspective for our younger listeners. So, not too long ago, arthrodesis or effusion was favored over arthroplasty, and the majority of ankle arthrodesis were performed through a transfibular approach. Today, with many foot and ankle specialists favoring ankle arthroplasty over arthrodesis, the vast majority of ankle replacements are performed through an anterior approach. So I suspect that this historical perspective may have influenced you and the other design surgeons to favor a lateral approach. Could you take us through the rationale for the lateral transfibular approach and total ankle replacement? And just in simple terms, why do you go through the side window instead of going through the front door to do your ankle replacement placements?

B (4:33)

Yeah, so I used a little analogy. You know, if you're trying to attack a castle from the front and you keep having trouble, you know, the guys are, are throwing the oil on you, and they're, you know, the, the flaming arrows, and everybody's going from the front. Every time you try the attack, you fail. Go around the side. So that's, that's one of my philosophies of life, kind of. But also more critically, I was doing a lot of trauma, and we were doing a lot of revision trauma. So I had a lot of ankle fractures that were starting to get arthritis. And I would do a fibular osteotomy, as many of us do, to realign the ankles. So we had a little valgus, a little extra rotation, a little wideness and desmosis. Fibular osteotomy. Peel it down, realign the ankle, clean out the medial gutter, replate the fibula in a lengthened rotated position, close down the syndesmosis, and guess what? We won. And we won many times with that. And so the lateral approach was my friend. And not only did I do fusions that way, but all other preceding procedures, like peroneal reconstructions, lateral ligament reconstructions, the fibular osteotomies, for sure, was a powerhouse. And those procedures dominated my perspective on why we should go from the side. Because many of my cases are post traumatic cases and we have a fibular malunion somewhere in the mix. So you got to cut the fibula, realign the ankle, reestablish the mortise. I thought attack the castle from the side and that's, that's, it's the logical way. For me, I was always going from the side, so I stayed at the side.

A (6:17)

Great, thanks. That's helpful. Makes me think of Monty Python and the Holy Grail. But that's good. That's great. With not enough time to get into that. But with that said, you and your co authors report no cases of fibular non union and used iliac crest graft in every case to promote healing. Do you have any other tips and tricks for the listeners so that when they use this approach that they will limit their risk of fibular nonunion?

B (6:47)

Sure. As I mentioned, I've been doing fibular osteotomy since I was a child, so I have lots of tricks. My number one trick is given to me by my mentor, Mel Joss, and reinforced by my other mentors, including Don Baxter, which was don't use the tourniquet. So I don't use the tourniquet. I put the patient in Trent Ellenberg. These days I use txa. But back when this cluster of patients was started, we didn't do txa. It was all no tourniquet, all trendelenburg, and just careful hemostasis. So that allows the body to stay alive. During the surgery, I also irrigate copiously. We had three bulb syringes going and then we hooked up a different system where we ran it from an IV bag, you know, with a cysto tubing hooked to a Fraser tip suction, which we ran continuously in. So when I was doing the osteotomy, we were totally cooling the blade. I also, if we, if there was any smoking, we stopped. So that's super critical and I think those are helpful. In addition, I use bmac, bone marrow aspirin concentrate and cylinders of bone graft which I harvested with a Jamshidi needle. If there was a gap, I always filled it meticulously with either. Typically autographed, but sometimes I used allograft. But most of the time, if it was allograft was augmented with the bmac, which I put into the graft by sucking out the marrow elements in the allograft femoral head of something. If we had a big lengthening and then soaking the BMAC into the graft. And that really has improved incorporation rates in my experience. And, and if and the best is autographed, of course. The cylinders, what I call them love logs. They're 2 millimeter wide in diameter and sometimes 10 millimeters long. I take multiple cylinders and I'll fill my void, if it's not a big void, with the love logs, the cylinders, and then shoot it up with BMAC at the end of the case after everything's closed. That's when I put the BMAC in. So those are my tricks.

A (8:57)

Just really briefly, plate fixation all times. Or could you also use a fibular nail?

B (9:02)

Great question. And I realized I left that out of the equation. I plate everyone. I initially was doing a lag screw technique on everybody, but basically the lagging was not necessarily because I squeezed the osteotomy or repositioned the fibula in such a way that I could get it opposed really nicely squeezed. And then I put a plate on it. Typically I use a locking plate, but you could use any plate. I've done done it with screws sometimes. I know people have done it with nails. I know Federico Uzwelli uses a Z cut osteotomy and a couple screws. He's published on that. That has worked well in his hands. I'm a plate guy. I like to use the plate because I like to realign it meticulously. And then I also like to shoot a syndesmonic screw if I need to, or a suture construct to re establish the syndesmosis, which is not common. But when I have to do it, I want a plate to do that, not the rod. Got it.

A (10:05)

Okay, that's very helpful. Okay, just a little aside. So this is the first Foot and Ankle International article of the new year 2025. My understanding is that you are an expert in sounding the show shofar and tell me if I say that incorrectly, but would you briefly educate some of our non Jewish listeners on when Rosh Hashanah, the new year in Judaism, takes place and the significance of the shofar?

B (10:29)

Yeah, so this, this is from the Bible. So many faiths that that respect the Bible know of the shofar. And as one of my partners says, shofar so good. But basically the shofar was the first cell phone. It was a means of communication from one group separate from another group, and could be used to awaken people, to cause them to rise up, to cause them to focus. It's an alarm system. You could use it for all sorts of communication. And at our beginning of the spiritual new year, which is Rosh Hashanah, the beginning of the year, we are commanded to hear the sound of the shofar. We all rise and we are solemn and we reflect on the past year and the year going forward. And we meditate for good thoughts and peace and happiness and healing and love. And the shofar is sounded. And that's my job at my synagogue, is to sound the shofar.

A (11:36)

Great. Well, we'll get back to some more of your musical, well, somewhat musical talents. We'll say it's good. So over half of the patients in your study had coronal plane deformity. Would you please share with a team and the listeners your methods for correcting coronal plane deformity from a lateral approach? You already mentioned how you address the fibula, but if you had a few more tricks, let us know. And then you mentioned there were some issues with medial impingement after the surgery follow up. But it just, we need to know, when you do use a lateral approach, do you need a medial release to correct varus deformity? And if so, how do you access the deltoid ligament? And then I think you addressed your deformity correction with the fibula. But if you have anything else to add when you're, when you're addressing coronal plane deformity.

B (12:33)

Sure. We had about 27 valgus cases and some of them were up to 20 degrees of valgus. So with the val. Let's start with the valgus cases. So fibular osteotomy is done and we're going to, typically in a valgus ankle, have a shortened and externally rotated fibula. We may have the talus tilting and causing a stress fracture or stress reaction of the fibula. So the fibula is short and needs to be lengthened and typically internally rotated. So I design my osteotomy accordingly. So I'll make an oblique kind of Weber B style osteotomy. And that way at the end of the case, I could correct the coronal plane as well as do some rotation and do some translation to follow the talus back in the mortise. With good alignment, once the fibula is down, I then take a cob. I release anterior posteriorly. I get basically everything released except for the deltoid. Now, typically in a valgus, you don't have a deltoid contracture. Usually you have a deltoid that's loose. So in those cases, we then put the ankle in the frame. This uses a distractor calcaneal pin, pull it, realign the tails to get it level, Talus pin gets put in. Then we coronally correct the tibia and this is using image intensifier. And then we get our fibula. Sorry. Then we get our tibia aligned in the coronal plane. And then we get a. A lateral X ray and pull the tibia anteriorly or posteriorly to get the tibia over the talus. That's done with a pin. It's then held and locked in position, typically in a valgus case, distracted. So we're pulling tension on the deltoid in the frame and getting everything completely aligned. I've looked at the patient preoperately. I watch them walk. I see what their knees doing, their hips doing. So I know how to align them proximally. Usually I'm using the medial tibial spine at the knee as my alignment point, but sometimes I want to overcorrect it into a little bit more varus, depending on what's going on. Or sometimes we want to undercorrect it if that's where the patient needs to be based on their other side or other radiographic parameters. And then with that distraction, I'm actually cutting into a void. So I'm taking very little bone away in those distracted cases. And again, nothing to do with the deltoid because I've already stretched it. Then we mill it away. Our implant is 15 millimeters top to bottom from front to back. We don't have any because it's a curved implant. It's the same width front to back as it is in the center. And then we mill that. Then we put in the implant, and then generally it's stable. If. If we find that we still have some laxity, we do a plus two or plus four poly. But typically that's. That's not the case in a valgus. We may still have some laxity. And then the. And then. Then add the plus 2 or plus 4 poly. Then we fix the fibula straightened so that it's no longer in valgus, so it supports the lateral ankle, and then we repair the ligaments. If the deltoid's loose, will do a suture construct, suture tape construct on the medial side, or an allograft at the same time. Also, the foot needs to be balanced as well. So if you have a heel valgus, you may need to do a calc osteotomy or a cotton osteotomy to rebalance the foot. In terms of the varus cases there, you do have a tight deltoid. Same thing's done. A fibular osteotomy is made, oblique osteotomy, but this time we're thinking we may have to shorten it, because if this talus is invaginated into the tibia and you've got the loss of bone there, you can have a really rigid deformity. And sometimes it's so rigid you can't pull it out of that tibia. Sometimes you can, sometimes you can. But we are prepared potentially to mill away a bit of tibia to make a correction. So we're taking away like an intra articular osteectomy and we're milling away the bone on the lower part of the tibia. So we can take that talus that's stuck in the, the mortise into a more central coronal position and correct that. And then once we've taken that tibia away, that will bring the talus around, distracted with the talus, the calcaneal pin, the talus pin coronal plane, the tibia, and then flip it to the lateral view. Sagittal correction, pulling it forward or back, whatever we need to get the alignment. We also, by the way, correct rotation so we could externally and internally rotate it to get the alignment as well. We didn't discuss that. But then, then we plate, put in the implant and plate the fibula. Now, if we have a varus deformity, that is a loose deformity, that's pretty easy. Cut the fibula, put your cob in there front and back, and suddenly the ankle will correct with just distraction. And you don't have to do that pre cutting of the tibia to get the correction. So you pull traction, it stretch, stretches the deltoid and then you follow from there. Now, if we have a bad varus, which we had some, I think we had the hardest one was 25 degrees. In this, in this series, you typically will have big osteophytes in the medial gutter, loose bodies, impingement, then we will make that incision to chisel that out. And when we do that, separate medial incision just around the saphenous vein. Watch out for the saphenous vein, sizzle out the shoulder of the talus, which is on the medial side, and the anterior aspect of the medial malleolus, and take out whatever loose bodies you got there. And that releases the superficial deltoid. So I don't deliberately do a deltoid, deep deltoid release, but sometimes, maybe by distraction I'm releasing it. But I've not actually cut the deep deltoid, but I do sometimes cut the superficial deltoid to get out the osteophytes. So those are my big tricks. It's a very powerful way to correct deformity. I've corrected, you know, 35, 40 degrees. Not in this series. We're going to publish on that as well with the tips and tricks.

A (19:10)

So no cases of subsidence or loosening at six and a half years average follow up. And that's really impressive for any total ankle replacement series, as you mentioned. Would you share with the listeners some techniques, methods and protocols to help our listeners be able to achieve these similar results? In particular, I think think you mention it for the fibula, but you mentioned that you use a router to prepare the tibia and prepare the talus. How do you avoid heat necrosis? And you may have already mentioned that you just don't want to limit bone on growth or ingrowth. And then you also, your, your fellow, you and your fellow design team members chose trabecular metal for the implant backside. So what are the advantages of trabecular using trabecular metal. And then just briefly, if you could just mention your post Artford protocol. You have early range of motion exercises. You do some squats for the patient. So the patient isn't doing any twisting. But there's no unprotected full weight bearing until 10 weeks. Are there times since the ankle does so well? There are times when you're confident enough that you could maybe allow earlier weight bearing. So one is just how do you use a router and not burn the bone? Why do you use trabecular metal? And just a few tips on your post operative protocol.

B (20:32)

Okay, I'm going to take it in reverse order. So the we do allow full weight bearing. At two weeks, it's full weight bearing. It's not full weight bearing for ambulation though. So full weight bearing is allowed. At two weeks out of the splint, they stand and they are taught to do knee bends, to dorsiflex the ankle and to do Achilles stretching where they're leaning into the wall and putting full weight on it. And I think that really helps. So it is full weight bearing at that point and that's done 100 minutes a day is what we strive for. Not everybody does it, but I think most people do something close to that based on our discussions with the patients. So we start the full weight bearing walking typically at six weeks and that's done in a boot, but they are allowed to do some cheating. We do have patients who are younger and healthier and they have better bone and we will allow them to do some full weight bearing with some steps earlier and some People have actually been even more aggressive and done full weight bearing and walking, despite our instructions not to earlier. Even at two, three weeks, we don't like that because we want the ankle to rest. We don't want swelling, we don't want to limit range of motion. We want to optimize that if they're doing 100 minutes of full weight bearing and stretching, they may get a little swelling. So we don't want them to get more swelling with the walking on it. Federico Uzuelo uses a aggressive post operative protocol where he lets them weight bear some patients in a cast right away. And that's a protocol which he's written up and published. But I don't generally do that. They can rest their leg on the ground to go to the bathroom those first two weeks. Otherwise no. So that's weight bearing full at two weeks for the range of motion exercises. Now, in terms of going to the tantalum. Tantalum, atomic number 73, is a metal that tantalizes bone. That is where the word came from. It was a Greek mythology figure. And tantalum is a metal that is highly attractive to bone. And bone will grow in it, has a high coefficient of friction, it has a very high boiling and melting point and is very resistant to corrosion. It's a metal that is pretty magical. And the metal is constructed, the metal part of the implant is constructed by taking the metal and vaporizing it. So it's sublimated into a gas and then that is laid down under a carbon scaffold which has got the porosity of bone. So that same porosity is created with the tantalum interface both on the tibia side and the Taylor side. So that ingrowth, I think is really powerful. And that's why we used it. We saw the other problems with the other implants and we thought I needed to change, we all needed to change everything. And this process of using the tantalum seemed to be ideal now in terms of the best way to get it to, to adhere and avoid loosening, necrosis and subsidence. First off, as I mentioned, we're distracting the ankle and correcting the deformity. So we are actually cutting into a void. So our cuts are going to take the least amount of bone. And there's been a couple of articles written on it in foot and ankle where we've demonstrated or other authors have demonstrated that we're taking the least amount of bone. So by taking the least amount of bone in a curved cut fashion, we are getting the greatest surface area. We're resurfacing the talus, going front to back with a very broad radius. And we're resurfacing it so we have a large surface area in high density bone because we're taking very little bone. So it could be 5 millimeters from the talus. So you're still in very high density bone. Then you've got your gap, which is distraction, and then you have your tibia cut, which is similarly curved. Resurfacing the lower tibia again, because you're distracted. You're in the highest density bone and, and getting the broadest surface area. A curve gives you more surface area than a flat cut because you're cutting up a trapezoid. And the higher you go up in the trapezoid, the, the less surface area you have. And so we're going low down on the trapezoid, low at the base, and making a curve cut and giving a very broad surface to get our implant on of high density bone. And I think those are critical tricks. I mentioned the irrigation. No smoking in the or. Hello, what's going on here? Irrigation should be continuous. Used the bulb syringes back in the day at this study, but then subsequently used the IV tubing with the Frasier tip suction. Running the irrigation continuously. Again, no tourniquet for me these days. I use the txa, but we do the Trendelenburg and meticulous hemostasis going in. And those are my tricks, and I'm sticking with it.

A (26:08)

That's great. All right, thank you. I think that we just have a couple more questions and we'll get to the end. But I believe that in his core article 20 years ago, this is a reference that you cited. Chris Kutsia introduced the concept of radiographic assessment of ankle range of motion using weight bearing, dorsiflexion and plantar flexion lateral radiographs. I think that his emphasis was that tibiotalar range of motion could be isolated from tiber tibiopedal motion with the pedal component often compensating for a lack of tibiotalar motion. With your excellent objective reporting of both tibiotalar and tibiopedal motion, why do you and your co authors now emphasize tibial pedal motion in your study?

B (26:54)

Yeah, I think the answer comes down to kind of a practical perspective. We know that when we watch a patient with a successful fusion, for example, when they do their gait, you'll see them move their ankle. Well, they're not moving their ankle. It's a tibiopedal motion. And those patients that have beautiful compensatory motion can do pretty well. Eventually they'll wear out their subtalar joint because it's a little goofy. It's a hinging motion versus the side to side motion that the subtalar joints used to. But from a functional point of view, that tibiopedal may be more critical for success than actually the range of motion at the tibial talar junction. So I like that from a practical point of view, we'll see people do, you know, deep knee bends and sometimes they're down 25, 30 degrees of dorsiflexion. We're like, oh my God, that's amazing. Well, that's tibio pedal motion. And when we look at that radiographically, you may drop off another 10 or 15 degrees from the ankle joint, but it's coming from subtalar and ankle. But we were very pleased with both ankle specific motion and the whole complex of foot motion relative to the tibia.

A (28:18)

And I appreciate you breaking that down. That's very helpful when we analyze range of motion as we attach importance to it. So that was really good to give us objective findings for both you and your co authors. Provide excellent patient reported outcome measures, range of motion, radiographic data, follow up, and offer a comprehensive explanation for the lack of preoperative data and the lack of follow up for nearly half of the other total ankle patients operated in the dates of study. While you acknowledge these major limitations, you mentioned that there are no major data differences to those patients. Without adequate data to be included in this study, could you just please provide us with some reassurance that this is indeed the case?

B (29:06)

Yeah, so we, I have patients from all over and many of them were far away. So we did, we didn't lose them to follow up. We just didn't have all their data. So we have. I'm in touch with just about 99.9% of my patients. And as you know from having been with me, I stay in touch with the patients. That's my M.O. and, but we didn't get full data on everybody to be included. So we may have the radiographs, we didn't have the proms, so there were pieces missing. But for the patients that we didn't get, because we didn't at the time of this 83, some of the patients were all set but didn't have consent. So that was another thing. So the 83 had everything, full package. The other patients, the next cluster were 130 patients, which we'll be publishing on very soon. That was basically a Little longer term follow up. But we got more of those early cluster of patients to finish all their data. So if they were missing X rays or they're missing proms, we collect them. And I could assure you that there were no outliers in this cluster. Everything was as is. And we, you know, the people not included look the same. And, and you will see in subsequent 130 patients that it really is, you know, the same data basically as we had. So it was really a matter of contacting the patients, getting them to come in, getting all the forms, getting everything done. It's a lot of work. I also changed hospitals. That was another thing. We had several irbs that we had to go through. And then when I shifted over, I had a reestablished contact with the patients. So it was a journey. But now that we've got everybody, pretty much everybody in the data bank, we have I think 550 with almost complete data and we will ultimately have I think 700 patients to report on. But right now that we don't have, obviously two year follow up on all, all 700.

A (31:20)

That's good. Yeah, it's tough. Research is tough. But thank you for the explanation. We look forward to the further research. One more aside and then we'll, we'll finish up. You've played music for years, your whole life, including a family band with your boys. Your son Jeremy has taken it to the next level on guitar and vocals for the popular nationwide touring band Pigeons playing ping pong. And many may not know this, but you had your big stage moments twice at Boston's Fenway park, covering the white striped Seven Nation army. And then the Ramones Blitz Creek Bop with Dave Grohl and the Foo Fighters. So I have a very important, important related question. What was more difficult? Preparing to perform live with the Foo Fighters or your first lateral approach? Total ankle arthroplasty.

B (32:06)

So, as you know, I don't use the tourniquet. I irrigate continuously. Oh, I'm sorry, I didn't know. What was your question? Just joking. Yeah, so, yeah, so you got to irrigate. Okay. So you gotta drink, you gotta hydrate, and you know, don't choke, you know, don't use the tourniquet. So basically preparing for the performances. You know, I have my own band, the Stimulators, My, my son's band. I've, I've done some guest appearance with them and Jeremy's played with me as well. I mean, we, we're used to being at music. Erica's a musician as well. So I think it's kind of natural, so I don't really stress out about that. I probably am a bit more razor focused when it comes to surgery and maybe it's, you know, you're worried about ambushes during surgery. I wasn't so worried about any of my musical performances being ambushed, but I do think about it. But I think the prep is a little bit more relaxed. And even though there might have been 35 something thousand people in the audience when I'm operating out, one patient in the audience and that's my focus. And to me that requires laser focus and is more austere. And although I relax and listen to music in the or, you know, I think prepping for a case is, is, is more critical and requires more focus and energy than, than a musical performance. That's, that's for, that's in my perspective.

A (33:45)

Great.

B (33:45)

Mark, I want to, I want to mention one other thing which I didn't mention. We use highly cross linked polyethylene. I was thinking one of the major components we didn't discuss is that was critical in our design to use highly cross linked polyethylene. And I think that also contributes to what we're seeing is, you know, nowhere. And we, I didn't mention that before, so I wanted to emphasize that that's.

A (34:11)

Good, that's really important. Thank you. Yeah, so it's excellent work. As we come to a conclusion here with this podcast, is there anything else you'd like to share with the listeners?

B (34:21)

No, I just think that, you know, you gotta think what's best for your patient, analyze their deformities and, you know, think about their unique issues and address it during your reconstruction and hopefully do very creative mechanical work to get them to a better place. And that's our goal as foot and ankle surgeons. So I hope this has helped other people to achieve those goals. And I really thank you, Mark, for this interview and appreciate all you do for our society and for the world of foot and ankle.

A (35:00)

Well, as you told, told me years ago, you know, you are not a stargazer. You are certainly a shuttle commander. So that's great. I'd like to thank you for sharing your insights and we also want to thank your co authors for this Foot and Ankle International publication. Transfibular total ankle arthroplasty. Clinical, functional and radiographic outcomes and complications at a minimum five year follow up. And I would like to thank everyone for participating in this month's Foot and Ankle International podcast.