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Foot & Ankle International
FAI November 2025 Podcast: Patient-Specific Instrumentation Does Not Improve Alignment Compared to the Extramedullary Foot Holder for the INBONE II Total Ankle Arthroplasty
00:31:35
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- [00:00]
A
Foreign this is Mark Easley, and I have the distinct honor of talking with Dr. Scott Ellis, the senior author of November's lead paper on Foot and Ankle International. The paper is titled Patient Specific Instrumentation Does Not Improve Alignment Compared to the Extramedullary footholder for the inbone 2 total ankle arthroplasty. Dr. Scott Ellis is Professor of Orthopedic Foot and Ankle Surgery at the Hospital for Special Surgery and the President Elect for the American Orthopedic Foot and Ankle Society. Scott is a friend and an internationally respected clinician, researcher and educator. Dr. Saltzman and I selected this article that compares a single institution's outcomes of total ankle arthroplasty, specifically the inbone 2 performed with the traditional technique using a footholder versus the patient specific instrumentation or PSI technique. Welcome to the program, Scott. Scott, as senior author, would you please provide the listeners with a brief summary of your paper and its major findings?
- [01:03]
B
Mark, thank you for having me and for all that you have done and continue to do for our field and for FAI to push our field forward. And so you're an expert on total ankle too. So I'm interested to hear the questions you have, but I actually prepared a little statement of the article to make sure I can do it succinctly. But in essence, we know that patient specific instrumentation is well established in total ankle replacement and that's true for many different implants. Now, the implant we're going to talk about today, the inbone, initially was designed for using a jig, an extra medullary device, and it's the only stemmed implant, large stem. I should say that I know that does that. There's many advantages to that traditional jig and you can correct lots of the components of the deformity and it's under the control of the surgeon. So varus falgus, right rotation, medial lateral joint, line height, and there's many tricks. It's done with a monoblock cut, which I think is going to be important as we discuss this more. The PSI is nice because you can do a specific plan which then allows you to decouple the cuts, balance the ligaments and can be done very accurately and thought out before. So there's many people or surgeons that have done the in bone. It's been around even when I was a fellow some 20 years now, and I think that those surgeons are comfortable with it. But newer surgeons tend to like psi. And as I look through it, we didn't ever have or see a study that compared the accuracy of alignment for PSI versus standard instrumentation for the inbound. So we wanted to compare it. And we did that by taking 46 patient specific and matched a cohort of the extramedullary jig by age and sex. And we had 46 in the standard jig. We compared fluoroscopy time, deformity, correction, alignment, radiation and and or time. I do have to say this is going to come up. Most of the PSI patients were mine and most of the jigs were Dr. Demetri Coplos, and both of us have a lot of experience in each results. Briefly, the patient specific predicted the correct size in 60% of the talus. Most of those that was changed was just downsizing the talus and it predicted the size 89% of the time in the tibia. Usually when there was a discrepancy that was just downsizing from a long to a standard, we looked at the alignment. Like I said, there was an absolute deviation in the AP varus valleus alignment of only 1.3 degrees on the APB, I should say in 1.8 on the lateral. And the tibial Taylor angle was less than 2 degrees on average. Fluoro time, interestingly, was 92 seconds in psi and 104 in standard, which was not significantly different. And PSI actually had a longer tourniquet time, 156 versus 134 minutes. And procedure time was actually 188 minutes for psi and 161 for standard. So longer tourniquet time, longer overtime for psi, I think at the end of the day. And we'll talk more if you put in the implant well, they're going to do well. That seemed the case in this study. Although we did not test clinical outcomes, PSI is accurate. We talked about why there was differences with tourniquet time and procedure time, but probably reflects the surgeon experience. So that's the summary, Mark.
- [04:07]
A
Great Scott. So I appreciate that. And so you answered this somewhat already, but my next question was just do you or have you used patient specific instrumentation when performing total angle replacement? Obviously, that's the case for this study and you touched on some of these. But would you just review with the listeners what you see as the major advantages over the standard technique when you use psi?
- [04:31]
B
Yeah. Okay. So for me, psi allows you to have control of all the components of the deformity and really map it out before surgery. It does take some time before surgery, so I think that's important to note. I think it gives a lot of people confidence at the time of surgery that they're lining up ankle the way they planned. You do Lose a little control at the time of the surgery though, because you really have to rely on those guides and just follow through with it. I mean, you can abort it and go to standard instrumentation. The standard affords you some other tricks with laminar spreaders and using the jig that you can't have with psi. And you can really control a lot of the more surgical decision making at the time of surgery. So I like it. I feel like in general, it's just giving me more confidence to map my pre plan out. But you could see why you might use either.
- [05:20]
A
Good. You're an established expert in total ankle arthroplasty and you continue to teach established surgeons and trainees on how to optimize their outcomes with this procedure. Do you believe it's necessary for a surgeon to first learn the standard technique for total ankle replacement before performing PSI total ankle surgery, or is it acceptable for a surgeon to immediately start with the PSI technique?
- [05:44]
B
Well, when it first came out, I taught all the residents and fellows that you should definitely know the standard instrumentation because you want to know in case you ever have to just like I mentioned, abandon the PSI and go to the standard, because if you get stuck and you don't know how to use it, you're in trouble. The only caveat with that or the issue that I've seen over time is since I really started using psi, I've not had to abandon the plan a single time. So the truth is, I think as you learn more and more and you know all the subtleties of the PSI and ligament balancing, et cetera, I'm not really sure you need to know the standard instrumentation. And even more so, I think some of the implants coming out, especially a newer version of the stemmed implant we're talking about, may not even have the typical jig. So I actually would say that you don't absolutely need it. So I have not gone back to it in a long time.
- [06:34]
A
Good. I think that's important. Information technology has really come a long way. A few more details about the surgery and in your paper post operatively, you assess coronal plane component alignment using the anatomic axis and commented on reasons for using the mortise view. Would you please describe your technique of assessing alignment based on the anatomic axis when only the distal 1/3 of the tibia is projected on a standard ankle radiographs also. Has that technique been validated?
- [07:05]
B
Yes. So what was fascinating to me as we started looking at these, I just assumed it was very standard, the way you would measure these parameters. But two things came up. One, most people actually and in the literature, the way they validated this measurement is on an AP X ray. And I actually find that looking at a mortise X ray is so much better and easier because you're looking right down the gutters and in line with what the rotation of the implant should be and the ap. Often you see some overlap, but the validation has actually really been only done for the ap. So we extrapolate a little bit revalidating and apply the same parameters of measurement to the mortise view. So you could argue there's a difference. I don't actually think there would be. And then another thing that came up as we got our X rays, we realized a lot of our X rays didn't go as high as the standard literature would say. So the standard way to measure is up to 130 millimeters above the ankle joint. And a lot of our X rays only went up to about 115. So you draw these perfect circles along the tibia cortex and you put a line right down the middle. So we actually brought down our points and measured 1 at 50 and 1 at 100 millimeters as opposed to 85 and 130 millimeters. So we brought it down and you could argue there's differences there because I'm not seeing quite up to the knee. So maybe for the listeners, when you get those X rays maybe get a little higher, have your radiology techs get a little bit higher and 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, in which case you should probably be getting X rays even up to the hip. Right.
- [08:34]
A
There's a lot of information there, but it's good to know that you can work off even just the distal segment and be as accurate as you are. Just to take that previous question one step further. When planning preoperative intended tibial component position using the CT based PSI is the entire tibia used in the planning and when you compare the final postoperative component position to the intended position from the preoperative PSICT planning, how well did the preoperative CT assessment of the anatomic alignment correlate with the postoperative plane radiograph assessment of the anatomic axis?
- [09:14]
B
Yes. So the answer to the first question is you definitely should. I believe and really the way the PSI plans are mapped out is you should do the whole tibia axis. And so I use weight bearing CAT scan, you can Use regular CAT scan too, because I use that for years. But you have to have segments of the knee and obviously the ankle because you draw down an anatomic axis. In the case of a stemmed implant, in a non stemmed, I tend to use mechanical axis or somewhere in between. There are a few cases where for some reason the techs forgot to do the knee or somehow didn't go through. And then the engineers will ask me if I want to just use the distal tibia. And I've done that and it's been okay. But you have to make sure there's not significant bowing in the tib, kind of like I mentioned before. And basically our data showed the answer to the second question, that we were pretty darn close, because in all of these implants, almost all I should say, I intended to be right along the anatomic axis compared to my psi. And on average I was about 1.3 degrees away, which really means that we're close. And as I mentioned in the summary, we were less than 2 degrees of a tibial Taylor angle of 90 degrees. So I think it showed it's quite accurate.
- [10:22]
A
It's amazing technology. I've used it. And I'll just share one story with you. One of the earlier ones I did with psi, I was looking at it intraoperatively and I put the guide on the tibia. And I was so frustrated because it was in what I interpret to be about 20 or more degrees of external rotation. I said, how can this be so far off? And so in the operating room I then, obviously not sterile, but I called the engineers and I said, how could you make such a mistake? And they said, Dr. Easley, calm down. Let's just look at this after the surgery. So I actually abandoned the PSI technique and I converted to the standard technique, thinking that I was so far externally rotated, how could it be a mistake? And how could they be so far off when the technology is so good and I'm used to using the medial gutter? And you'll describe that too a little bit more on the standard technique. And then I looked at the plan afterward and the plan was absolutely accurate. It's where I had put the external guide in my planning. So the planning always matches very well as you describe what your initial preoperative plan is. It's just that I've never seen the three dimensional analysis. And the tibial component fits so nicely when I look down the axis that I basically forgot to look at how I like to typically rotate it according to the medial gutter. And I made it fit more, just fitting it in the axial plane. And so I externally rotated because at least in my mind, that's how it fit well. And I said, never seen that before in that view. And so for me, it was just a good lesson that it's a really accurate technology, but it still depends on the preoperative plan that I put together. So, anyway, that's good to know that you were that accurate.
- [12:05]
B
And it also, like you said, like, you just do PSI and you forget about it. It still requires a lot of judgment and making sure you know where those guides are supposed to go. So it takes effort in surgery, too.
- [12:16]
A
Yeah, but it's so good. All right, I'll go on a little bit on a tangent. With your expertise and all the things that you do, you're a member of the AOFAS Board of Directors and next in line to become the AOFAS president. So what do you perceive as the greatest challenges facing the AOFAS in its mission to serve its membership?
- [12:36]
B
Well, thank you, Mark. I always love digressing, and I appreciate that on the podcast, too, because fai, at the end of the day, is the journal for the society. It's how we push our field forward. But the number one challenge I'd say we face is recruiting people into foot and ankle orthopedic surgery. Every year we have a lot of fellowship spots that go unfilled. You know, of course, as a society, we want to grow our membership. And every year we're just trying to find ways to bring more and more people into foot and ankle. And I think the biggest reasons is I've thought about it over time, are the perception of the reimbursement and how that might compare to other subspecialties. I think there's a lot of time concerned about scope of practice debates as it relates to podiatry. I think there's some perception that foot and ankles is diabetic foot, and that's certainly not been the case. So we have a lot of initiatives trying to recruit young, promising people in the field, like our Resident Scholar program for the residents, where we pave the way for them to come to our annual meeting and meet us. And it's just an incredible field because the job market's wide open. There's so much research and development available. It's kind of like the project we're talking about tonight. And there's so many different surgeons or surgeries to do rather, and really a really fun group of people, both in the US and internationally. So a tremendous group to be with I'd encourage everybody that's listening to this, it's not already decided. Consider a career in foot and ankle orthopedics.
- [13:55]
A
Well said and certainly challenges, but it's an exciting field. I agree. There's so much opportunity, so thanks for making that clear to everybody. Scott, in the non psi total ankle arthroplasty, I find determining optimal tibial component rotation challenging. As to my little story I just told, so it's along those lines. You and your co authors briefly mentioned that for the standard technique you used an osteotome in the medial ankle gutter to adjust and set rotation. PSI affords detailed 3D axial imaging to set tibial component rotation. As you have previously studied, post operative CT affords optimal assessment of tibial component rotation. But you did not utilize CT in the follow up of these patient cohorts. In your evaluation of postoperative plane radiographs, do you and your colleagues have a technique to determine success of intended tibial component axial plane positioning?
- [14:54]
B
Yeah, I think that's the biggest unknown in all of total ankle and we're not even sure what the right answer is in terms of how to put the implant in to make sure it lasts the longest or has the best clinical outcomes. And the answer is we did not do that in this study. I have been getting weight bearing CAT scans routinely on all my total ankles and we intend to look at this down the line to see exactly what you just said is we'll do all the parameters, but weight bearing CAT scan, does the intended axial alignment match what we sought out to do? And actually as we started to look at it, it's harder than you might think because the way the engineers determine the gutter bisection, which is how I do on the psi, I go right down the middle of the medial lateral gutter. It's based off these 3D models and it's really hard to measure off of weight bearing CAT scan post op because you've cut bone number one. I debride the gutters also, which makes them even hard to determine where they are and then you have the implant there. So actually it's even harder than you think to measure. We know based on a previous study published in FAI that impingement can occur more frequently in patients where you internally rotate the Taylor compared to the tibia. So that's just not really tibial rotation, but it's. I think there's something to it. And I think down the line, as we say this more, we really, as I mentioned, have to compare clinical outcomes to rotation because we don't know what the right answer is.
- [16:11]
A
Yeah, that's a big question for me too. So thanks for at least pointing out that it's still a challenge. So we'll continue to learn more and thanks for doing the research for it. You and your colleagues reported that irrespective of which technique was used, final component position was satisfactory and similar. However, you noted that you were surprised by the unexpected findings of surgical time, fluoroscopy use and tourniquet time not being less using the PSI technique. And I recognize that the majority of cases were yours for psi and that Dr. Dimitri Kopulous did the standard technique. I agree that total ankle replacement should not be a race. But why do you think that there was no advantage in these particular outcome measures when using the PSI technique?
- [16:55]
B
Well, it was almost a little embarrassing, to be honest, Mark, when the results came out, especially for me to have to admit to Konstantin that he was still faster. But there's something to that. I mean, I've done a lot of them. He's done hundreds too. So he just really good at the jig and knows all the nuances. So I think the more cases you do, no matter how you do it, you're going to get quicker. I think it's important to note though that the PSI for this implant for the in bone is a little bit different because it still has a jig. So you make your bone cuts generally I decouple them, but there's still, even after that there's an apparatus, it's like a miniature version of the jig that has nylon guide that also fit on and you construct the jig around. You have to ream and do all this. So there's still a lot of the procedure that you're still doing that you're not avoiding. So I think that's probably why we didn't see as much a difference also. And when we did a similar study, I think it was probably five or six years ago with a low profile implant, we really found more advantages as in terms of or time and tourniquet time and even fluoro time. So the difference is probably in the continued need for a jig of some sort and the reaming and the stem and everything else that goes with it. So it makes this one. The PSI is not a lot different.
- [18:05]
A
Right. And so my other question I prepared really is probably redundant, but I'm very good at the Department of Redundancy department, so I'll go ahead and just ask it anyway. And you may have the same answer. But The In Bone 2 total ankle system uses an intramedullary tibial reamer and assembly instruments introduced through the plantar foot and optimally aligned with the system's foot and ankle holder. For listeners unfamiliar with the Inbone 2 psi prophecy system, would you briefly describe the psi procedure steps following bone resection with the PSI cut guides? Specifically, does the technique include the same steps of intramedullary tibial reaming and instrumentation introduced through the plantar foot? And if indeed the steps following bone resection are similar for both techniques, do your findings suggest that the time spent properly positioning the PSI cut guides was similar to properly positioning the leg and the foot and ankle holder?
- [19:03]
B
Yeah, that actually is not that redundant, Mark. I mean, it's really a great point. I think that the time that you prepare to make sure those guides are exactly matched, you just told a perfect story about it, 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 before you pin it and get ready for your cut. So I think that's the same, and you're exactly right. Once you make the cuts, it's very similar. In fact, I tell the fellows now, and actually for the fellows who've done the jig before, it becomes very familiar to them, and I tell them now, you're about to do the same thing you do with the standard instrumentation. You do have a little more control if you want to make small adjustments in the reaming with the psi because there's a little flexibility, you can move your hand one way or the other to change the orientation of the reaming, but it's essentially the same after you do that. And so that's probably also why it evens out at the end.
- [19:55]
A
Thanks for clarifying that. Irrespective of the standard of PSI techniques being used, a surgeon cannot preoperatively determine ankle soft tissue tension. That is where the ankle is tight or loose. In my hands, ankle soft tissue tension influences the amount of bone resection, prompting greater bone resection for tight ankles and less bone resection for loose ankles. Do you and your colleagues have a way to assess ankle soft tissue tension preoperatively? And if so, would this influence planned bone resection with the PSI technique or potentially using, like you described before, a lamina spreader for their standard technique when limiting bone resection is favored?
- [20:34]
B
That is such a great point. And so if there's one case where you might want to just do standard, it's a very loose ankle, and I would say especially Loose valve significantly valgus deformed. Because in my experience, what you do with that is you use a laminar spreader, standard jig and try to stretch it out. You take less bone cuts and that tightens the deltoid and that really helps you control that. So the problem with the PSI is you're basing your cut off the pre op plan. You can't stretch it out now. You can take less bone. If you want to go back to the engineers on the PSI plan, pre op, tell them, I want to cut less bone. But you kind of have to think that out ahead of time. And it's not something you can determine at the time of surgery based on how loose it is. But you should be thinking about that, especially in a loose valgus ankle. You could also, by the way, couple the cuts with psi, even though they're designed mostly to decouple them. But if you put a laminar spreader in there and pin the ankle in a performing completely corrected to do this. But you could stretch it out, pin it and then put your tibia guide on and just cut everything at once. So that's another way around it. And the other way is you just start increasing the size of the poly. But you got to be a little careful because you can't make up everything with just increasing the poly. So I think you're right on. I just watch out again for that loose valgus ankle.
- [21:53]
A
Good. Thanks. Yeah, a little digression again. You continue to build an extraordinary career. You have a busy practice, you're productive in your research output, you are regularly on the international lecture circuit and you effectively participate in organizational leadership. What advice do you have for our listeners, especially our younger surgeons and trainees who strive to achieve even some of what you have achieved. And how could they balance this with family life as you do so well?
- [22:24]
B
Again, I'd love to digress. So it's a little bit embarrassing, Mark, but I'll tell you some things I tell the fellows. So just a list of like five things, one set aside time. I've always set aside one day per week. Used to be just for research. Now a lot of times it's for conference and travel. You have to set aside some time to build a team, especially for research. And this involves, I think, getting a senior mentor when you can. Jonathan Deland was a huge mentor for me as I started building my practice and research. We have a team of research assistants and statisticians. The relationships with our fellows in residence has been so key, it's mutually beneficial so that's so important. You can start a registry and all that means is just collect data on your pre op patients. And it's so easy just to collect some standard baseline scores because then you can go back and do so many studies, find a niche. I start off with flat foot because do something that you can do well and do research in and then it just develops and grows. And one thing I've always said is try to submit an abstract to our annual meeting and the winter meeting every year. Just one thing. So if you have small goals, you'll end up achieving a lot. And then for work, life balances. I think you just need to block off weeks at a time that you go on vacation. One thing I've learned is let your spouse figure out where you're going to go because that goes a long way. And then what I found really fun with these trips internationally and nationally is you can also take your family with you. So it's a time that you get to go see something you've never seen before and actually spend time with your family.
- [23:53]
A
That's good advice. I try. You do a much better job than I do. People ask me, wow, you went to some great country. That's far away. How was it? I usually come back with the same answer. I said, well, it was 72 and fluorescent and I just spent the whole time at the meeting. Definitely good advice.
- [24:12]
B
You don't leave the hotel, right? Or the conference center.
- [24:15]
A
I know, I know. Well, good advice for everybody. In the introduction to the abstract and manuscript and in the statistical methods section, you and your co authors suggest that clinical follow up was also included. Did you observe a clinical difference in outcomes between the two techniques?
- [24:34]
B
No, as I mentioned before, we didn't study it. We may have said that loosely, but if you notice in the paper there's no patient reported outcomes and we weren't looking at survivorship. And I've always said survivorship's not the end all be all. But we didn't. But that's, I think the next steps because we got to look down the line is does this really matter? And have results that are 2 and 5 and at some point in 10 years. And I think what you do is find the survivorship but also compare to well established and validated patient reported outcomes and we'll know even more. I suspect you and your group has the paper that shows doesn't matter what the deformity is pre op, if you put the implant in well aligned, you're going to have similar clinical outcomes. I think that's what you're going to see with this study. It doesn't matter whether you use PSI or standard jigs. If you put it in straight, you're going to have the same outcomes and good outcomes.
- [25:20]
A
Good. Thanks. You're an accomplished researcher. We've been over that and once again prove it with this paper and have published extensively on outcomes of total ankle arthroplasty. For this study, you and your investigators acknowledge the limitations of retrospective analysis and also a surgeon technique correlation which is evident or you described it for this paper. What would you do differently if you conducted the same study as a prospective study?
- [25:47]
B
Well, I mean the obvious bias we talked about is just the same. Surgeons were doing each of the different implants. I think you could randomize patients as to whether you do PSI or not. You'd have to get the surgeons to do it. I don't know that the patients would care so much. They randomize the surgeons. You could randomize whether you do PSI or not just based on the patient. I would get surgeons involved, especially at an institution like ours has a large number at different stages in their career to see if it makes a difference early versus late. And like you just asked, I think one thing missing is just to compare clinical outcomes in the two groups.
- [26:19]
A
Thanks. Standard in Bone two technique has a unique alignment system to properly align the bone cuts and the total ankle components in two planes using fluoroscopy. Do you believe that your findings would have been similar had you compared a different total ankle systems PSI and standard techniques? A system that does not rely on that foot ankle holder like the Inbone 2 does?
- [26:42]
B
Yeah. We touched on this before, Mark and I completely agree and actually there's other papers, but the paper we did before, it was on the infinity. It showed actually that there was definitely more time savings in terms of overtime fluoroscopy and actually less. So there's no questions that those without a footholder and there's many out there, obviously they would be quicker and have more advantages with psi.
- [27:06]
A
Good, thanks. We touched on this too. One last digression. I asked you about your work life balance with your full plate. Do you have any time for hobbies?
- [27:17]
B
Yes, I think I do the big ones. And over time I play classical piano and I try to play. I have a couple pianos actually at home. And most of my time actually now is spent teaching my daughter. So she's getting a lot better. I may not be, but it's been fun. I love to travel. My wife is from Spain and we go to Spain all the time. But Also other Spanish speaking countries. And that has just been a passion. It's so much fun. Kind of like we mentioned with the conferences, I'm getting a little old for this, but soccer has always been a passion of mine. I'd love to follow the Spanish league. And one that may surprise you, Mark, is I'm starting to be an avid Legos collector. So I've done the Apollo 13, this, the Bernabeu stadium in Madrid and a grand piano, and I just finished the Millennium Falcon, which took me like a year. So that's been a lot of fun.
- [28:10]
A
Wow, that's very good. So the millennium felt like from Star wars, like Han Solo's. Yep. Yeah, I'll never. The best scene, of course, is when Han so is about to be frozen that time and then Princess Leia looks across and says, han, I love you. And he says, I know.
- [28:29]
B
My favorite too.
- [28:30]
A
Yeah, that was good. Yeah, no, that's impressive. Just Legos are also good for foot and ankle surges. Job security. Because if you step on a Lego, your foot will never be the same.
- [28:39]
B
I thought you were going to say that they help for your spatial skills.
- [28:43]
A
Oh yeah, that too. Okay, good. All right, we're almost here. Getting toward the end. I have one more question regarding the paper. You and your co investigators confirmed that PSI was accurate in comparing final implant position and intended preoperative implant position for the inbound too. Have you used PSI for other foot and ankle procedures? And where do you see further opportunities to use PSI in foot and ankle surgery?
- [29:08]
B
Me, it's like all these. Mark, I wish you could answer your own question because you might give an even better answer than I am based on your experience. But there's no question it's going to help us in so many realms. So perfect example and you've worked on this is the bunion. If you could map out a correction in all the different planes. And we've been so interested in that pronation rotation more recently and have patient specific guides that you put on and there's companies and I know you've worked on some that are looking at it. If you could put some guides on there and guide that cut, it could really help patients. Whether I think the one I know the most is a lapis, but whatever the system is, I think it really helped. I just did my first case last week of a super malleolar osteotomy with a PSI guide and I think that is going to be 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. And then the other one. For me, maybe it's partly because my interest is flat foot. So you can guide the different osteotomies you might need, how to cut it, where to cut and how much to translate and then the betas. Whether you use weight bearing CAT scan for it, I think probably gives you more accurate results, especially for flat foot. The problem is it's not widely available, so I think we're learning how to use multiple X ray views to extrapolate that kind of information.
- [30:23]
A
Great, thanks. So congratulations to you and your colleagues on another impactful research effort. As our podcast comes to its conclusion, is there anything else you would like to share with the listeners?
- [30:35]
B
Well, just a couple. One this study actually was just a very simple study and I just was curious. I actually I want to recognize Charlotte Jones, who is the medical student who helped me on it. It was her summer project. So you can find any simple project that can answer a very meaningful clinical question and create a lot of conversation. Like we've had reiterate to young people, foot and ankle is an incredible field and potential career. So seriously consider it. And for those of you that have 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.
- [31:06]
A
Good, thanks. That's a good concluding message. So I'd like to thank Dr. Ellis for sharing his insights on his and his co author's FAI publication. Patient specific instrumentation does not improve alignment compared to the extramedullary footholder for the inbound 2 total ankle arthroplasty. And I would like to thank everyone for participating in this month's FAI podcast. This is Mark Easley. I look forward to next month's podcast.