Foot & Ankle International – November 2025 Podcast

Episode: Patient-Specific Instrumentation Does Not Improve Alignment Compared to the Extramedullary Foot Holder for the INBONE II Total Ankle Arthroplasty
Date: November 27, 2025
Host: Mark Easley
Guest: Dr. Scott Ellis, Professor of Orthopedic Foot and Ankle Surgery, Hospital for Special Surgery, President Elect for AOFAS

Episode Overview

This episode examines the findings of a key study recently published in Foot & Ankle International comparing patient-specific instrumentation (PSI) to the standard extramedullary footholder technique in INBONE II total ankle arthroplasty (TAA). Dr. Scott Ellis, the senior author, discusses outcomes, surgical nuances, training implications, and future directions for PSI, offering both data-driven and practical insight for clinicians and trainees.

Key Discussion Points & Insights

1. Study Summary and Major Findings

• Comparative Aim:
  The study compared INBONE II TAA performed with traditional extramedullary jig versus PSI, specifically evaluating alignment accuracy, fluoroscopy time, deformity correction, procedural time, and radiation exposure.

  • Cohorts: 46 PSI cases (primarily by Dr. Ellis) vs. 46 matched standard jig cases (primarily by Dr. Kopoulos).

• Major Findings:

  • Alignment accuracy was nearly equivalent for both techniques:
    • Absolute deviation in AP varus/valgus alignment: 1.3° (AP), 1.8° (lateral).
    • Tibial-talar angle <2° on average.
  • PSI predicted correct talus size 60% and tibia size 89% of the time (usually discrepancies were minor, e.g., downsizing).
  • Fluoroscopy time: 92 seconds (PSI) vs. 104 seconds (standard) – not significantly different.
  • PSI had longer tourniquet (156 vs. 134 minutes) and procedural times (188 vs. 161 minutes).

  "At the end of the day... if you put in the implant well, they're going to do well. That seemed the case in this study."
  – Dr. Ellis [03:30]

2. Practical Surgical Considerations

• Advantages of PSI:

  • Enables detailed, preoperative planning and mapping of deformity correction.
  • Surgeons gain confidence knowing the plan is customized.
  • Main limitation: Less intraoperative flexibility; must rely on the guides, though can switch to standard if needed.

• Advantages of Standard Jig:

  • Greater intraoperative control and opportunity to use surgical “tricks” (e.g., laminar spreaders).
  • Real-time decision-making possible.

  "The standard affords you some other tricks with laminar spreaders and using the jig that you can't have with PSI... so you could see why you might use either."
  – Dr. Ellis [04:52]

3. Training and Surgeon Experience

• Do Surgeons Need to Learn the Standard First?

  • Historically recommended due to potential need to abandon PSI mid-operation.
  • In practice, Dr. Ellis hasn't needed to revert from PSI back to standard, suggesting it may not be strictly necessary, especially as newer implants may lack traditional jigs.

  "I'm not really sure you need to know the standard instrumentation... I have not gone back to it in a long time."
  – Dr. Ellis [06:09]

4. Alignment Assessment Techniques

• Radiographic Technique:

  • Traditionally measured using AP radiographs, but Dr. Ellis prefers mortise views for visual clarity, acknowledging that this is a small departure from validated methods.
  • Sometimes, only the distal 1/3 of tibia is assessible due to X-ray field limits. Dr. Ellis adapts landmarks accordingly, but stresses the importance of higher radiographs or long views—especially in tibial deformity.

  "We brought it down and you could argue there's differences there... probably we do need to validate it, although I suspect it's really not going to make a big difference unless you have deformity of bowing in the tibia..."
  – Dr. Ellis [07:53]

5. Correlation Between Preoperative Planning and Postoperative Alignment

• PSI Planning:

  • Whole tibia anatomic axis preferred (knee to ankle).
  • Data showed mean deviation between plan and final position was only 1.3°, with tibial-talar angles also very close.

  "On average I was about 1.3 degrees away, which really means that we're close."
  – Dr. Ellis [09:46]

6. Real-World Anecdotes & Memorable Quotes

• On learning curve and clinical intuition:

  "PSI is a really accurate technology, but it still depends on the preoperative plan that I put together."
  – Dr. Easley [11:29]

• On intraoperative judgment:

  "It still requires a lot of judgment and making sure you know where those guides are supposed to go."
  – Dr. Ellis [12:05]

7. Field & Community Insights

• Challenges Facing Foot & Ankle Orthopedics:

  • Recruitment is a major challenge; foot and ankle surgery remains often misunderstood, with perceived reimbursement issues and scope of practice debates.
  • Initiatives like the Resident Scholar program encourage new talent and raise awareness of the field's diversity.

  "It's just an incredible field because the job market's wide open. There's so much research and development available."
  – Dr. Ellis [13:25]

8. Technical Questions About Procedure

• Tibial Component Rotation:

  • Still a challenge; optimal rotational alignment and its clinical impact remain incompletely understood, and more research utilizing weight-bearing CT is planned.

• PSI & Standard Steps Post-Bone Resection:

  • Both require analogous steps after initial resections; the time difference may be minimal due to similar setup requirements.

  "The time that you prepare to make sure those guides are exactly matched... is probably in the end, very similar to the time it takes to put that leg in the jig properly and get it lined up."
  – Dr. Ellis [19:08]

9. Soft Tissue Tension and Bone Resection

• Intraoperative Soft Tissue Balance:

  • While PSI is based on pre-op planning and may limit intraoperative flexibility, there are workarounds, especially for notably loose/valgus ankles, but the standard jig remains preferable in select scenarios.

  "If there's one case where you might want to just do standard, it's a very loose ankle..."
  – Dr. Ellis [20:39]

10. Reflection, Mentorship, and Work-Life Balance

• Advice to Young Surgeons:

  • Set aside protected time for research and conferences.
  • Build a strong team, find senior mentors, and create registries for continuous data gathering.
  • Start with achievable goals (e.g., submit one abstract per year).
  • Take meaningful vacations and involve family on work trips when possible.

  "If you have small goals, you'll end up achieving a lot."
  – Dr. Ellis [23:08]
  "Let your spouse figure out where you're going to go because that goes a long way."
  – Dr. Ellis [23:35]

11. Study Limitations & Future Directions

• Current Study Limitations:

  • Retrospective design with surgeon-specific technique bias.
  • No patient-reported outcomes or survivorship data included.

• Prospective Study Recommendations:

  • Randomize patients/surgeons to technique.
  • Assess outcomes at different career stages.
  • Include validated clinical outcome measures.

• Generalization to Other Implants:

  • Systems lacking the footholder (unlike INBONE II) might show greater PSI efficiency benefits.

12. Opportunities for PSI in Foot & Ankle Surgery

• Broader Application:

  • Bunion and other forefoot corrections.
  • Supramalleolar osteotomies.
  • Flatfoot reconstructions.

  "There's no question it's going to help us in so many realms... a huge area because you can confidently put some guides on, pin it, direct your cut and then even help you with hardware and really map out a perfect correction."
  – Dr. Ellis [29:16]

13. Personal Notes and Lighthearted Moments

• Dr. Ellis' Hobbies:

  • Classical piano ("most of my time actually now is spent teaching my daughter.")
  • Traveling, especially to Spain and Spanish-speaking countries.
  • Soccer fandom (Spanish league).
  • Avid Lego collector ("I just finished the Millennium Falcon, which took me like a year.")
    [27:23–28:09]

• Favorite Star Wars Quote:

  "The best scene, of course, is when Han Solo is about to be frozen that time and then Princess Leia looks across and says, Han, I love you, and he says, I know."
  – Dr. Easley [28:18]
  "My favorite too."
  – Dr. Ellis [28:28]

14. Final Takeaways

• Even simple, focused clinical questions can yield impactful, actionable studies.

• Alignment accuracy in INBONE II total ankle arthroplasty is good with both standard and PSI techniques; clinical outcomes likely depend more on execution than instrumentation.

• The field of foot & ankle surgery offers wide career opportunities; finding a niche and passion can make for a rewarding career.

  "Find a niche, find something that you're passionate about, a small part of foot and ankle and I think your career could be very rewarding."
  – Dr. Ellis [31:00]

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